APPLICATION FORM FOR U-ROC LEADERSHIP™ GAP YEAR PROGRAM

We'd like to get to know you better! Let us know what your interests, dreams, and long-term goals are by filling out our 2023 application:

Name

First Name

Last Name

Address

City

Zip

Phone

(###)

###

####

What year did your graduate from high school or get your GED?

What kind of job interests you? Why?

Name & contact information of parent or guardian

Home Address

City

Zip

Parent/Guardian Cell Phone

(###)

###

####

Parent/Guardian Personal Email

What would you most like to see be different in our world or country today?

How would you like your own life to improve? (Such as better job, go to college, buy a car, get into shape, or anything else that you would like to have in your life that is not currently there.)

What parts of your life would you like to improve by attending the U-ROC Leadership™ Gap Year Program?

What are your strengths and key qualities that you bring to the U-ROC Leadership™ Gap Year Program?

What do you consider to be your most significant skill or achievement so far in your life?

When it comes to what you will do to make money so that you can live independently, what is most important to you?

What are your values? What do you want others to respect?

Would you consider yourself a leader? Why or Why not?

Important U-ROC Leadership™ Program Details:

An Orientation for participants and family members will be scheduled prior to the start of our 2023 classes. We encourage parent(s)/guardian(s) to attend – siblings are welcome too! Classroom sessions usually begin the week following Orientation and are scheduled for Mondays and Wednesdays from 10 a.m. to 3 p.m. Fridays are a flexible day when we may schedule one-on-one consultations; a field trip to a college or corporation; or work together on a non-profit project. Any changes to the schedule will be communicated with as much advance notice as possible. Are you able to commit to attend all U-ROC sessions? The expectation is for as close to 100% attendance as possible. Participants are asked to request prior approval for an unavoidable absence. We do understand that emergencies may arise, or you may get sick, and have no choice but to miss class. In this case, we ask that you text Dana or Janet to let us know what’s happening. Re-occurring absences will impact the quality of your experience and those of your classmates, therefore will be addressed, and may put your participation in the program in jeopardy.

I Agree

I Disagree

If no, please explain here:

Thank you for applying to U-ROC Leadership™ Gap Year Program

Applications are now being accepted for our 2023 classes. We have set a program cost of $200 a week, but we do not want this cost to be a barrier to your participation. Scholarships are available. Also, paid internships, which are an integral part of our program, will help you afford this fee. Please apply, and we will discuss the financial arrangements with you privately and confidentially. We do not want tuition to be a barrier for participation. Please apply even if you do not have the money. Please contact Dana Riker Jackson at 610-566-8272 to answer any questions you may have. The information I have provided in this application is, to the best of my knowledge, correct. I understand that if any of the information above is found to be incorrect, my application will be denied.

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