Application
for Clifford R. Nyquist Youth Leadership Award
Name (Last,
First, MI):____________________________________________________
Current Address:
________________________________________________________
City/Town:
E-mail: ____________________________ Birth Date (mm/dd/yyyy):
__________ Age: ____
1. Briefly describe your objective or opportunity: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________
2. Amount of funding requested: $___________ (Max. of $250.00 for 2007)
3. Describe your timeframes/deadlines and specifically how these funds will be used:
______________________________________________________________________
______________________________________________________________________
____________________________________________________________________________________________________________________________________________
______________________________________________________________________
4. Describe your
personal, measurable goals and objectives and how this grant will help to
achieve these goals (500 words. Use a
separate sheet of paper.)
5. List three
references, who are not related to you and whom we may contact regarding this
application:
Full Name:________________________ Phone:______________E-mail:____________
Relationship (neighbor, teacher, coach, etc):_______________________________________
Full Name:________________________ Phone:______________E-mail:____________
Relationship (neighbor, teacher, coach, etc):_______________________________________
Full Name:________________________ Phone:______________E-mail:____________
Relationship (neighbor, teacher, coach, etc):_______________________________________
6. Would you
agree to meet with the selection committee after you have completed your
objectives to briefly report on your experience? ____ Yes ____ No.
By my signature
below, I confirm that the written answers submitted reflect work produced by
me, unedited by others.
Signed:________________________________________ Date: __________________