Youth LEAD Application

Participant First Name:

Participant Last Name

Participant Cell Phone:

Home Phone:

Participant Email Address:

Home Street Address:

City:

State:

Zip Code:

DATE OF BIRTH

Birthdate

Ethnicity

Gender

Do you qualify for free & reduced lunch?

YesNo

Are you applying for a Scholarship?

YesNo

How did you hear about ETC’s Youth LEAD Program?

Do you have any special needs we need to know about?

Parent/Guardian First Name:	Parent/Guardian Last Name:
Parent/Guardian Email Address (if none, leave blank):	Parent/Guardian Primary Phone
Parent/Guardian Alternate Phone

Ref 2: First Name	Ref 2: Last Name
Ref 2: Phone	Ref 2: Email