LEADERSHIP APPLICATION Name * First Name Last Name Home Address * Cell Phone/Home Phone * (###) ### #### Name/Address of Employer * Occupation * Gender * Email Address What do you feel are the strengths (music skills, creative skills, previous relevant volunteer experience, etc.) you can bring to the program? * What previous experience do you have in the industry? * What motivates you to participate as a leader? * What individual has served as a role model for you? Why? * Please check to agree to the three statements below: * I understand that the iCreate leadership program involves spending a minimum of 2 hours a week with a group of high school students for teaching and training and encouraging the next generation. I understand that the iCreate program involves a weekly commitment on Tuesdays and/or Thursdays for a 12-week period. I understand that I will be required to complete the leadership orientation and a two-hour iCreate training session. What day/time can you commit to (please check all that apply): Tuesday 3-6pm Thursday 3-6pm Within the past 10 years, have you been convicted of any felony or misdemeanor classified as an offense against a person or family, or an offense of public indecency or a violation involving a state/federally controlled substance? Yes No Are you under current indictment or has a district/county attorney accepted an official complaint for any of the offenses in question #6? Yes No Educational Background (mark one): * Some high school High school graduate Some college College graduate Graduate/professional school Technical school Other (please specify) Please list two references: * Name, Address, City , State/Zip, Phone number, Relationship * I understand that the iCreate program routinely performs background & child abuse clearances according to PA requirements, of all the volunteers for the position for which I am applying. These checks may be done if I sign below. I certify to the best of my ability that the information provided on this application is true and accurate. I also understand that misinformation knowingly provided here, and on subsequent mentor application forms, is grounds for dismissal. Date * MM DD YYYY Thank you!
