Participant Information*

		First Name		Last Name
Student Info

Applicant Information:*

		Preferred Name (Nickname)		Gender
Student Information:

Participant Information*

		Birthdate (M/D/Y)		City		State
Student Info

Participant (Student) Contact Information:*

		Preferred Email Address		Phone Number
Student Information:

5.	Please indicate below if you are in need of special accommodations (dietary needs, allergies, medical conditions needing special attention, etc.):*

6.	What are your current Activities/Hobbies?*

7.	What are your previous leadership experiences?*

8.	What do you hope to gain from the Leadership & Service Institute?*

9.	How do you hope to contribute to the Leadership & Service Institute?*

10.	Describe your interest in cross-cultural collaboration.*

Leadership & Service Institute runs from August 25-28, 2013.

Leadership & Service Institute is free. There is no cost to participants. Complete this online application by July 15, 2013. Participants will be selected by the quality of their application. There is no cost to participate in the Leadership & Service Institute.

Participants will be notified byJuly 19, 2013, of their selection. If you have any questions, please contact The Office of Diversity Programs & Multicultural Affairs at 724-503-1001 ex 3540 or Diversity@washjeff.edu .

11.	I understand by selecting "Yes" below that I agree that if selected, I will participate in the Leadership & Service Institute August 25-28. *