YLA Application - Virginia Board for People with Disabilities

Student Information

Student's Name(Required)

First Last

Birthdate(Required)

Gender(Required)

Male

Female

Home Address(Required)

Street Address City State ZIP Code

Is mailing address different than above?(Required)

Yes

Student Mailing Address(Required)

Street Address City State ZIP Code

Home Phone(Required)

Student's Cell Phone(Required)

Student's Email(Required)

How would you like us to communicate with you?(Required)

Mail

Home Phone

Cell Phone

Photo Upload

Accepted file types: jpg, png, gif, pdf, jpeg, Max. file size: 64 MB.

Please upload a photo of the applicant (optional)

Parent/Guardian Information

Parent/Guardian Name(Required)

First Last

Is Parent/Guardian Address different than student's home address above?(Required)

Yes

Parent/Guardian Address(Required)

Street Address City State ZIP Code

Parent/Guardian Home Phone(Required)

Parent/Guardian Cell Phone

Parent/Guardian Email(Required)

How would you like us to communicate with you?(Required)

Mail

Home Phone

Cell Phone

School and Community Involvement

Name of High School(Required)

High School Phone(Required)

School Mailing Address(Required)

Street Address City State ZIP Code

High School Counselor or Transition Specialist Name(Required)

First Last

High School Counselor or Transition Specialist Email(Required)

High School Principal's Name(Required)

First Last

High School Principal's Email(Required)

Grade level on December 19, 2024

Anticipated Graduation Date(Required)

Please list the school classes in which you are currently enrolled:(Required)

Briefly list your involvement with your school and community. This may include any offices you held, club memberships, after school activities, volunteer activities or work experiences.(Required)

Type of Activity

Year(s) of Involvement

List the type of activity and year of involvement.

Briefly describe some of your interests and hobbies that you pursue in your free time.(Required)

Letters of Recommendation

At least two references must complete our Letter of Recommendation Form, which describe why you (student) would benefit from this personal, leadership and career development program. One reference must be a high school representative (teacher, principal, counselor, coach) and one must be a community representative (representative of a civic or social activity, employer, neighbor, religious leader or representative) outside your school (not a relative). Please share the Letter of Recommendation Form link with your references. These references may complete the form online or download and e-mail the form to: training@vbpd.virginia.gov.

Important: The Letter of Recommendation Forms must be received by the Virginia Board for People with Disabilities by 5:00 p.m. on Friday, March 28, 2025.

Ethnicity/Disability Information

Race/Ethnic Background(Required)

Do you have a Developmental Disability?(Required)

Yes

What is your disability (developmental or other disability)?(Required)

How does your disability affect your life?(Required)

Tell Us About You

Tell us why you want to participate in this personal, leadership and career development program.(Required)

How did you hear about the YLA program (name of the teacher, friend, program, and/or website)?(Required)

Required Signatures

The student’s parent/legal guardian gives permission for the student applicant, if selected, to participate as a Delegate to the 2025 Virginia Youth Leadership Academy. The student’s parent/legal guardian gives permission for the Virginia Board for People with Disabilities (VBPD) to share the answers to the questions on this application with YLA staff, YLA applicant interview panel, and the YLA selection committee.

By entering my name below, I certify that I am the applicant represented by the information on this application, as well as guarantee that all of the information provided is accurate to the best of my knowledge and has been voluntarily disclosed. For the purpose of the YLA application submission, the insertion of your name on the signature line qualifies as an electronic signature.

Parent Signature(Required)

Type full name

The student applicant is interested in being a Delegate to the Youth Leadership Academy and, if selected, is committed to completing the program.

Submitting false information in an application will disqualify the student from participating in the program.

Did you (student applicant) complete this application on your own?(Required)

Yes

No, I had help completing this application (it was filled out and/or submitted with my input).

Student Signature(Required)

Type full name

Online Application

Student Information

Parent/Guardian Information

School and Community Involvement

Letters of Recommendation

Ethnicity/Disability Information

Tell Us About You

Required Signatures