Youth Lead Application Form

Youth Lead Application Form

We will need signatures on this form when we meet in person at Orientation
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
E-mail*
example@example.com
School*
Grade (as of Fall 2025)*
MaleFemale
Birthdate*

MonthDayYear
Which Indian languages can you speak proficiently, if any?*
Parent/Guardian #1 Name*
Parent/Guardian #1 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #1 Email*
example@example.com
Parent/Guardian #2 Name
Parent/Guardian #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2 Email
example@example.com
YesNo
Organization/Business #1
Start Date

MonthDayYear
Supervisor
Supervisor Email
example@example.com
Roles and Responsibilities (50-75 words)
Do you have additional experience you'd like to share?
Why do you feel you are a good fit for the ICA Youth "LEAD" Program? How will this experience benefit you? (up to 200 words)*
YesNoMaybe
YesNo
YesNo
Deposit Amount*

prevnext( X )
USDPlease complete the required $100 deposit to secure your spot in the Youth Lead Program.
Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info
Should be Empty: