<p> Fairfax County Youth Leadership Program Preparing tomorrow’s Leaders Today</p><p>DUE DATE – October 31, 2012</p><p>Please send application to: Department of Management and Budget, Suite 561 12,000 Government Center Parkway Fairfax, VA 22035 Attention: Martha Reed</p><p>Applications are available at: http://www.fairfaxcounty.gov/dmb/FCYLP.htm Please type your application if at all possible. </p><p>School: ______</p><p>Your Name: ______Last First Middle Initial</p><p>Address: ______Street</p><p>______City State Zip Code</p><p>Phone Number: ______E-mail Address: ______</p><p>Are you a High School Junior? Yes ______No </p><p>Are you legally able to work in the United States? Yes No Note: Included in parentheses are the maximum number of points which may be awarded by the selection committee for each section.</p><p>Personal Information: Use the space below to provide the selection committee with additional information about yourself. </p><p>1. List all after school activities including: extracurricular school-based activities, work experiences, volunteer work, etc using the chart below. Use additional sheets if necessary. (Maximum points possible – 10)</p><p>School Year Activity Position Held</p><p>2. List any significant honors or awards you have received for either academic or extracurricular activities. (Maximum points possible – 10)</p><p>3. What qualifications do you possess that you think make you a strong candidate for the Fairfax County Youth Leadership Program? (Maximum points possible – 5)</p><p>4. Do you have any special skills (foreign language, computer, etc.) that may be useful during the summer internship? If so, please indicate here. (Maximum points possible – 5)</p><p>5. Essay Question On a separate sheet of paper, answer the following question in a typed, 350-500 word essay: Discuss three ways that Fairfax County Government affects your everyday life. (Maximum points possible – 10) Staple your essay to this part of the application form.</p><p>6. Recommendations: Please submit two recommendations. One or both recommendations may be from a teacher, activity sponsor or guidance counselor who is familiar with your work, your interests and extra-curricular or volunteer activities. The other recommendation MAY be from a supervisor with whom you work on community or volunteer activities. (Maximum points possible – 10, 2 @ 5 points) Note to Student: By signing this application, in addition to committing to be present at the monthly meetings, you are indicating that you will make yourself available for the internship from July 8 - July 26. You are acknowledging that you understand that you cannot make other commitments for this time period, including commitments to school activities such as Governor's School, etc.</p><p>______Student Signature Date</p><p>Note to Parent/Guardian: By signing this application you give permission for your child to participate in the Fairfax County Youth Leadership Program including all out-of- school activities, many of which will take place after regular school hours. In addition, by signing this application, you understand that FCPS will not furnish transportation for off- site activities and individual students will need to provide their own transportation. In addition, by signing this application you understand that your child will commit to their internship from July 8 - July 26 and other commitments will not be made during that time frame.</p><p>______Parent/Guardian Signature Date</p><p>Note to FCPS representatives: By signing this application you are indicating that this student is in good standing.</p><p>______High School Counselor Signature Date</p><p>______Grade-level Administrator Signature Date</p><p>APPLICATION DEADLINE – October 31, 2012</p><p>Please send applications to: Dept. of Management and Budget, Suite 561 12,000 Government Center Parkway Fairfax, VA 22035 Attention: Martha Reed</p>