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ABOUT C.H.A.N.G.E.
THE C.H.A.N.G.E MANTRA
Founders' Passion
Programs
Volunteer
Contact Us/inquiries
Home
ABOUT C.H.A.N.G.E.
THE C.H.A.N.G.E MANTRA
Founders' Passion
Programs
Volunteer
Contact Us/inquiries
Leadership Program Application (July 29-31, 2014) Elizabeth City, NC
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*
Indicates required field
Student's Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Current School
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Grade for 2014-2015 School Year
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Age
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T-Shirt Size
*
Please indicate your t-shirt size.
Parent/Guardian Information
Parent's/Guardian's Name
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Parent's/Guardian's Phone Number
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Parent's/Guardian's Email
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If you do not have an e-mail address, please input the following:
[email protected]
Please list other activities student is involved in:
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Does the student plan to take advantage of the overnight residential option? **Overnight Lodging is Available for a $65 flat fee for 3 Days and 2 Nights on the campus of ECSU. This is highly encouraged, but not mandatory. If staying overnight all participants are expected to stay the entire duration of the program.
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Yes, I will stay on campus.
No, I will not stay on campus.
The Overnight Option is highly encouraged, but not required.
Limited Sponsorships for Lodging costs may be available.
Contact
[email protected]
or Dr. Jametta Davis at 703-899-0482
What is the best way to reach you (Check All that Apply)
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E-mail
Phone
Text
Check All that Apply
Adult Recommendation
(Family Member, Family Friend, Community Leader, etc)
Name
*
Adult Recommendation can be a Family Member, Community Leader, etc.
Position/Relationship to student
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Why do you recommend this student for this program?
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Does the student display any behavioral issues that might interfere with working in a team environment during the workshop?
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No
Yes, Please Explain Below
Please explain any behavioral issues here.
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If the answer is no, please write N/A. If the answer is yes, please explain the behavioral issue(s) here.
What are some focus areas that woud benefit this student?
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All Applicants Must Complete This Section
My goals are:
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List your hopes, dreams, desires, or even your summer or academic goals. We just want to know more about you!
I want to improve in the following areas. Check all that apply.
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Communication
Courage
Confidence/Self-Esteem
Decision Making/Problem Solving
Focus/Self-Discipline
Motivation
Public Speaking
Teamwork
Time Management
Please tell us about yourself and why you are interested in the Girls Run the World Summer Leadership Program.
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We want to know more about you so we can tailor the workshop, so come on tell us a little about YOU!
Why do you believe it is important for girls and women to become leaders in society?
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There are no right or wrong answers here. Just write what you think.
Give one example of a way in which girls and women are negatively portrayed in media (TV, music, social media, etc.) and its impact on self-esteem.
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There is no minimum or maximum number of words for your response. Please answer this question to the best of your ability.
Applications can be submitted by pressing the button below, if you make an error or need to amend the application, please e-mail us at
[email protected]
or contact the Elizabeth City Program Director (information below).
Program Director:
Melba Smith, 252-335-3985,
[email protected]
Submit
