Junior Leadership Georgetown Application 2026-2027

DATES AND TIMES

September 12, 2026 9:00 am - 2:00 pm Opening Retreat October 21, 2026 4:30 pm - 6:45 pm Daring to Lead November 18, 2026 4:30 pm - 6:45 pm Social Services Day December 9, 2026 4:30 pm - 6:45 pm Public Safety Day January 20, 2027 4:30 pm - 6:45 pm Developmental Assets February 17, 2027 4:30 pm - 7:00 pm Juvenile Services March 10, 2027 4:30 pm - 7:00 pm Healthcare Day April 21, 2027 4:30 pm - 6:45 pm Local Government Day May 5, 2027 4:30 pm - 6:45 pm Final Speeches & Graduation Day **Meals are included during each session**

All session locations are subject to change. By completing this application, you understand that you may only miss four hours of the program in order to graduate from the program. Please note that if an emergency occurs, any participant who misses more than four hours, regardless of the reason, may be asked to withdraw from the program without a refund.

PROGRAM GOALS

• To build leadership skills and encourage civic engagement • To increase understanding of community needs and opportunities • To develop community pride • To motivate students for volunteer activities

PROGRAM FEE

The program fee is $150.00 and is non-refundable. This fee covers program supplies and meals. The fee is due once your child has been accepted into the program. Please make the check payable to the Georgetown Chamber of Commerce.

STUDENT CONTACT INFORMATION

First Name *

Last Name *

Nick Name or Preferred Name

Address

Address Line 1 *

Address Line 2

City *

Zip/Postal Code *

School *

What grade will you be in for the 2026-2027 school year? *

Age *

Full Birth Date *

Your Cell Number *

E-mail *

Will you be employed during the program? *

Total hour working per week?

Food Allergies, if any

Extracurricular Activities, if any

GUARDIAN #1 INFORMATION

Name *

Relationship to Student? *

Cell Number *

Alternate Phone *

E-mail *

GUARDIAN #2 INFORMATION

Name *

Relationship to Student? *

Cell Number *

Alternate Phone *

E-mail *

EMERGENCY CONTACT

Name *

Relationship to Student? *

Cell Number *

PROGRAM AWARENESS AND PERSONAL GROWTH

Describe your leadership style and experiences so far. *

What are your plans after high School? ( Please explain your future goals whether it is work, college, trade school, major, etc.) *

Describe your volunteer experiences, if any. *

Why do you want to participate in Junior Leadership Georgetown? *

What skills do you hope to gain from your participation in the program? *

How did you learn about Junior Leadership Georgetown? *

Is there anything else we should know about you? *

STUDENT CONSENT ACKNOWLEDGMENT *

I have reviewed the program schedule and will be able to participate in the Junior Leadership Georgetown Program dates listed above. I have my guardian’s support as indicated below, and we both understand the requirements outlined and agree to the Code of Conduct that has been provided in this application. I accept full responsibility for my personal conduct, actions, and safety throughout the duration of the program. I understand that if an emergency occurs, any participant who misses more than four hours, regardless of the reason, may be asked to withdraw from the program without a refund. I understand that there are physical requirements: Walking or standing for periods of time; Use of stairs, if necessary

This section is to be completed by the student

GUARDIAN CONSENT ACKNOWLEDGMENT *

I, the undersigned parent/guardian, have read the information about Junior Leadership Georgetown and am willing to allow my child to participate. I agree to pay the $150 non-refundable program fee. I understand that my student will be required to provide their own transportation. By submitting this application, I agree to release the Georgetown Chamber of Commerce, Jr. Leadership Program, and its affiliates from any legal or financial liability for personal injury, property loss, or damages incurred during my student’s participation in program activities. I accept full responsibility for my student’s personal conduct, actions, and safety throughout the duration of the program. I authorize any hospital, medical center, or physician to administer necessary emergency medical treatment to my child if they become injured or ill during any Junior Leadership Georgetown activity. In the event of an emergency, Junior Leadership Georgetown and its agents have my full permission to provide transportation to the best of their ability, and I remove all liability from the Georgetown Chamber of Commerce. I hereby grant full permission to Junior Leadership Georgetown and the Georgetown Chamber of Commerce to use my student's photo, name, and school information in any Chamber materials (printed or electronic).

This section is to be completed by the student's guardian

CHAMBER CONTACT

Cheryl Brinkmeyer Director of Programs and Events cheryl@georgetownchamber.org 512.930.3535