Youth Envision – Youth Application

PLEASE NOTE: Due to COVID-19, Mission Empower will be following PA Dept. of Health physical distancing guidelines and youth agree to cooperate with these guidelines.

Step 1 of 3

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• Student Demographic Information

• Name*
  First Last
• Are you a new or returning applicant?*
  • New
  • Returning
• Gender*
  • Male
  • Female
• Age*
  Please enter a number from 14 to 18.
• Place of Birth*
• Ethnicity*
  • White
  • Hispanic
  • African American
  • Asian
  • Other
• If other - please state ethnicity below
• Name of School*
• Grade*
• Youth Cell Phone
• Youth Email

• Parent/Guardian Information

• Parent/Guardian Name*
  First Last
• Relationship to Youth*
  • Mother
  • Father
  • Other
• If other, please state relationship below
• Parent/Guardian Name*
  First Last
• Address*
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country
• Parent/Guardian Home Phone*
• Parent/Guardian Cell Phone
• Parent/Guardian Email

• Emergency Contact Information

• Emergency Contact*
  First Last
• Relationship to Youth*
  • Mother
  • Father
  • Other
• If other, please state relationship below
• Address*
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country
• Emergency Contact Home Phone*
• Emergency Contact Cell Phone

• Application Questions (To Be Completed By Youth)

• 1. What are your dreams for your future?*
• 2. What are some obstacles you will have to overcome to achieve your dreams?*
• 3. Briefly describe what you would like to gain from your experience in the Youth Envision Program:*
• 4a. Are you willing to spend 12 hours a month for a minimum of one year to be part of the Envision Program?*
  • Yes
  • No
• 4b. Are you willing to attend the program’s 2-3 day long Summer Summit?*
  • Yes
  • No
• 4c. Would you like to have an adult mentor throughout the program?*
  • Yes
  • No
• 5. Do you have any transportation needs?*
• 6. Do you have a disability?*
  • Yes
  • No
  • I don't know
• 7. Do you have an IEP?*
  • Yes
  • No
  • I don't know

• By signing below, I verify all information listed on this application is accurate, and that I will commit to my participation in the Youth Envision Program.

• Youth Signature*
• Today's Date*
  Date Format: MM slash DD slash YYYY

• Information Release and Signature (To Be Completed by Parent/Guardian)

  If you are 18 or older, please complete the following information with your name in the Youth and Parent/Guardian fields.
• Youth's Name*
  First Last
• Today's Date*
  Date Format: MM slash DD slash YYYY

• I hereby grant permission for Mission Empower to make contact with my child and conduct a personal interview for the purposes of applying to be in the Youth Envision Program.
  
  We encourage parents to attend the interview with their child. Please provide a time & day of the week that works best for you.

• Example: M/W/F 3-4pm*

• I understand that basic information about my child will be kept private in accordance with HIPPA privacy laws. By signing below, I verify all information listed on this application is accurate.

• Parent/Guardian Signature*
• Today's Date*
  Date Format: MM slash DD slash YYYY

• We look forward to contacting you to set up an interview with you!

  
  
  

  Please be aware that submitting this application does NOT guarantee you a spot at the Summer Youth Summit. ALL applicants will be interviewed, screened, and given final consideration regarding their eligibility to join the program by the Youth Envision program coordinator(s) and Mission Empower's executive director. We thank all applicants for their interest in the program.

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