2017 Missouri Youth Leadership Forum Application

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2017 Missouri Youth Leadership Forum Application

July 18 - 22, 2017

Applications have to be postmarked by February 28, 2017. ONLY COMPLETE APPLICATIONS WILL BE CONSIDERED (Application, References, Resume, Essay).
Name: (First)       (M.I.)       (Last)      

Gender: Male Female Birth Date       Race (Optional)      T-Shirt Size      

Email Address      

Mailing Address      

City       Zip       County      


Current Grade       Expected Graduation Date      

High School       School Phone      

Parent / Guardian       Phone      
Please check the ones that apply:
How did you learn about the Forum?
school friend internet/email news article other      

I am a Vocational Rehabilitation (VR) or Rehabilitation Services for the Blind (RSB) Client

Yes No Don’t Know

I am a DMH Regional Office client. Yes No Don’t Know

Have you participated at your local Center for Independent Living (CIL)?
Yes No Don’t Know
Please describe your disability – (This will assist in assuring that we include delegates (students) with diverse disabilities)

Primary Disability (medical diagnosis):      Onset of Disability (age):      

Please check all that apply:

Deaf / Hard of Hearing:

I use sign language

I use assistive listening devices

I use real time captioning

I use lip reading

I need interpreter services

I use note takers

Blind / Visually Impaired:

I read with Braille

I read with large print

I need assistance with mobility

I prefer electronic format

Mobility Disability (e.g. spinal cord injury, muscular dystrophy, other):

I use a wheelchair / scooter

I cannot walk upstairs

I use a walker, cane, or crutches

I cannot walk long distances

Immune Disability:

Crohn’s Disease

Rheumatoid Arthritis

Sickle Cell Anemia



Asperger’s syndrome

Traumatic Brain Injury

Down Syndrome

Intellectual Disability

Mental Health Disability (e.g. anxiety, depression, bipolar/mood disorder, obsessive compulsive disorder, other)

Neuro/Muscular Disability

Learning Disability (e.g. dyslexia, dyscalculia, ADD/ADHD, other…)

Reading Math Written

Multiple Disabilities

Chronic Illness (e.g. cancer, cystic fibrosis, diabetes, heart disease, other)

Chemical / Environmental Sensitivity

Other (describe)      

Please list all accommodations needed to participate in the Forum (interpreter, personal care attendant, special diet, etc.)

Short answer and Essay:

Complete the following questions. If you are using a scribe to complete this portion of the application, please make sure responses are written reflecting your voice. If you have questions or need assistance with completing this application please contact Judy at 800-877-8249 or judy.grainger@oa.mo.gov.

  1. What organizations or activities are you involved in with your school and/or community? This may include any offices you held, club memberships, after school activities, work experience, church activities, community volunteer, etc.


  1. List 3 goals that you have for your future.


  1. List 3 leadership strengths that you possess.


  1. References

Please list three references that we may contact by phone. One reference must be a high school principal, counselor, or a teacher. The other references may be any adult who knows you well, other than a parent or relative, for example, scout leader, employer, coach, community leader, etc. At least one reference must be from outside the school.

1. Name (School)       Phone      

2. Name       Phone      

3. Name       Phone      

  1. Essay: Please complete an essay (maximum of 500 words) by answering the 3 questions below (Attach Essay (Word document) to your application):

  1. Explain why you would like to attend the Missouri Youth Leadership Forum and why you believe you have leadership potential.

  1. Describe an important experience you have had as a youth with a disability. (Please give specific examples as they relate to your disability)

  1. As a future leader, how do you see yourself making a difference in your community?

6. Attach a Resume: A sample resume is available at



Before submitting please verify:

  • Application is completed.

  • Essay addresses all three questions written in paragraph form.

  • 3 References with good contact numbers are given

  • Resume is attached

  • Send all documents to the Governor’s Council on Disability.

  • Must be submitted online or postmarked by February 28, 2017.

Please submit all documents together at the same time. Application, essay, and resume may be submitted online. If unable to submit online you may email, fax, or mail your documents to:
Governor’s Council on Disability

Missouri Youth Leadership Forum

PO Box 1668

Jefferson City, MO 65102



Phone: 800-877-8249

Fax: 573-526-4109

301 West High Street, Room 840 PO Box 1668 Jefferson City, MO 65102

800-877-8249 email: gcd@oa.mo.gov http://disability.mo.gov/gcd/ylf.htm

Missouri Youth Leadership Forum is hosted by

Governor’s Council on Disability and Paraquad

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