Rockdale Youth Leadership 
2017-2018

Thank you for your interest in the Rockdale Youth Leadership Program. You can be nominated by a student, parent, teacher, counselor, administrator, or by yourself to participate in this year’s program.  
Students must complete the application and have the reference forms completed by a counselor and a coach, teacher, or administrator at their school. 

Rockdale Youth Leadership (RYL) provides leadership development and community awareness training for 10th grade students in Rockdale County.  Through collaboration with the Conyers-Rockdale Chamber of Commerce and Rockdale County Public Schools, aspiring youth leaders will have the opportunity to interact with local decision makers and participate in community service activities.  During the program, students will interact with community leaders, local elected officials, and school administrators to enhance their awareness of community needs and resources. Through interactive workshops, special tours, and community service projects, RYL participants will develop the knowledge and skills necessary to become confident, caring leaders in their community and respective schools. To be nominated for participation in RYL, students must have met the following criteria:
•	Demonstrate leadership potential. (school/community)
•	Minimum 2.5 GPA.
•	Student in good standing with clear attendance and behavior records. (We review high school attendance and discipline reports.)
•	Willing to participate in community service activities.
•	Willing to participate in all sessions after school including some Saturdays.
•	Willing to pursue a school leadership role following participation in the program.
•	Complete the application in its entirety. 

The RYL program is held from September 2017 through May 2018.  Please review the entire RYL application packet to understand all of the requirements. The RYL Class of 2018 will kick-off on Tuesday, September 26, with an orientation session.  Please see the calendar inside for details. (Dates subject to change.)  Accepted students must attend the orientation session along with at least one parent.

The RYL application deadline is FRIDAY, SEPTEMBER 1.
Applications may be submitted electronically or as a hard copy.
•	Hard copy:  To submit a hard copy of the application, complete the form and return it to To submit a hard copy of the application, complete the form and return it to: DJ Youngblood, RMSST, 930 Rowland Road, Conyers, Georgia 30012. Must be received by the deadline. 
•	Electronic copy:  To submit an electronic copy of the application, complete the form, save it with your name in the file name, and e-mail it to DJ Youngblood at dyoungblood@rockdale.k12.ga.us.
Be sure that teacher and counselor references are sent in a timely manner, so the person 
making the reference can complete and return the form by the deadline.

If you have any questions or concerns, please contact:
Tami Maddox, RCPS Work-Based Learning & Youth Apprenticeship Coordinator
678-584-3080 (work cell) or tmaddox@rockdale.k12.ga.us

Rockdale Youth Leadership
2017-2018 Application
TYPE or PRINT NEATLY

Personal Information

Applicant’s Name:      

Name you prefer to be called:      

Home Address:       							Apt #:      

City, State, Zip:        	

Home phone:           						Cell phone:      

Your e-mail:      

Your age:                  		Race:                            	Gender:       

Your high school:       

Your career pathway:       

Hobbies/leisure time activities:      

Plans following your high school graduation:       

Select Your Shirt Size: (Men’s/Women’s shirt): 

X-Small     Small      Medium      Large      XL       2XL 

Parent/Guardian Name:      

Parent/Guardian E-mail:      

Parent/Guardian Cell Number:      

School and Community Involvement

Please list in ORDER OF IMPORTANCE TO YOU (up to six) any school, club, sports, civic, religious, social, employment, or other activities in which you are a participant. Include only those activities in which you have been involved since 9th grade.

	Organization	Position Held	Dates of Involvement	
School	     	     	     	
	     	     	     	
	     	     	     	
	     	     	     	
Community	     	     	     	
	     	     	     	
	     	     	     	
	     	     	     	
Faith-Based	     	     	     	
	     	     	     	
	     	     	     	
	     	     	     	

Have you been as active in school, community, 
or faith-based activities as you would like to be?
Yes q No q If no, what has been the major barrier to greater participation?	

Leadership Assessment
Please answer the following three questions in the space provided.  
Use additional paper if necessary.  
GRAMMAR COUNTS.  USE CORRECT SPELLING AND PUNCTUATION.  

1.	What is a critical issue facing your high school?  Please include in your response how this issue affects your education and how you see youth playing a role in addressing this issue. 
     	

2.	What is your personal definition of leadership? 
     	

3.	Describe your leadership skills.
     	

Rockdale Youth Leadership 2017-2018
Teacher, Advisor, Leader, Coach - Reference Form
TYPE OR PRINT NEATLY

STUDENT NAME:       							School:      

Rockdale Youth Leadership (RYL) provides leadership development and community awareness training for 10th grade students in Rockdale County.  Through collaboration with the Rockdale County Public Schools, Conyers-Rockdale Chamber of Commerce, and the RCPS Work-Based Learning program, aspiring youth leaders will have the opportunity to interact with local decision makers and participate in community service activities.  During the program, students will interact with community leaders, local elected officials, and school administrators to enhance their awareness of community needs and resources.  Through interactive workshops, special tours, and community service projects, RYL participants will develop the knowledge and skills necessary to become confident, caring leaders in their community and respective schools.  

How long have you known this student?      

RATINGS
Please rank this student in comparison to the general population at your school.	
	Needs Improvement	Fair	Average	Excellent	Outstanding	
Maturity/Responsibility						
Comments:      	
Attitude						
Comments:      	
Attendance/Punctuality						
Comments:      	
Problem Solving Skills						
Comments:      	
Interpersonal Skills						
Comments:      	
Personal Values/Ethics						
Comments:      	
Would you recommend this student for the RYL program?
     

	
	
Any qualities about this student you wish to share: 
     	

Teacher, Advisor, Leader, Coach Name:      				School/Organization:      
E-mail Address:        		
Contact Number and best time to reach if needed:      

Return Completed Referral Form by Friday, September 1, 2017, to DJ Youngblood, RMSST, 770-483-8737 ext. 29102,  dyoungblood@rockdale.k12.ga.us
Rockdale Youth Leadership 2017-2018
Counselor - Reference Form
TYPE OR PRINT NEATLY

STUDENT NAME:       								School:      

Rockdale Youth Leadership (RYL) provides leadership development and community awareness training for 10th grade students in Rockdale County.  Through collaboration with the Conyers-Rockdale Chamber of Commerce, the STARS Community Partnership, and the RCPS Work-Based Learning program, aspiring youth leaders will have the opportunity to interact with local decision makers and participate in community service activities.  During the program, students will interact with community leaders, local elected officials, and school administrators to enhance their awareness of community needs and resources.  Through interactive workshops, special tours, and community service projects, RYL participants will develop the knowledge and skills necessary to become confident, caring leaders in their community and respective schools.  

How long have you known this student?      

Is this student on track for graduation?      			Current GPA:       

RATINGS
Please rank this student in comparison to the general population at your school.	
	Needs Improvement	Fair	Average	Excellent	Outstanding	
Maturity/Dependability						
Comments	     	
Discipline Record						
Comments	     	
Attendance/Punctuality						
Comments	     	
Initiative						
Comments	     	
Communication/Listening Skills						
Comments	     	
Would you recommend this student for the RYL program?
     

	
	
Any qualities about this student you wish to share: 
     	

Counselor Name:      							School:      

E-mail Address:        

Contact Number and best time to reach if needed:      

Return Completed Referral Form by Friday, September 1, 2017, to DJ Youngblood, RMSST, 770-483-8737 ext. 29102,  dyoungblood@rockdale.k12.ga.us

Rockdale Youth Leadership 2017-2018 
Tentative Schedule*
Date	Day	Activity	Time	Possible Points	
September 1, 2017	Friday	Applications Due 	5 p.m. 	-	
September 15, 2017	Friday	Announce RYL class 	 N/A	-	
September 26, 2017	Tuesday	Orientation – RCA Auditorium	6 p.m. – 7:30 p.m.	2	
October 12, 2017	Thursday	 Leadership Retreat - RCA	2 p.m. – 7 p.m.	5	
October 23, 2017	Monday	Protecting Our Community	5 p.m. – 8 p.m.	3	
November 6, 2017	Monday	Working in Our Community	11 a.m. – 5 p.m.** 	5	
November 11, 2017 	Saturday	Teen Leadership Summit at RCA	8 a.m. - 12 noon	5	
November 30, 2017	Thursday	Dinner and Etiquette Instruction	5 p.m. – 7 p.m.	2	
January 11, 2018	Thursday	Caring in Our Community	5 p.m. – 8 p.m.	3	
February 6, 2018	Tuesday	Leading Our State	7 a.m. – 4 p.m.	8	
February 14, 2017	Wednesday	Leading in Our Community	2 p.m. – 5 p.m.	3	
March 1, 2018	Thursday	Culture in Our Community	5 p.m. – 7 p.m.	2	
March 13, 2018	Tuesday	Educating Our Community	2 p.m. – 5 p.m.	3	
April 14, 2017	Saturday	Giving Back to Our Community 	8 a.m.  - 11 a.m.  	3	
April 30, 2018	Monday	Graduation - RCA	6 p.m. – 8 p.m.	2	
Total Possible Points	46	
		 Points needed for Graduation	40	
Make up Meetings:  
•	Board of Education Meeting or County Commission Meeting:  1 point each
•	MLK Breakfast (January 15, 2018, at Longhorn's Steakhouse):  3 points
•	Fall Parent Academy (serve as volunteer minimum 3 hours) – September 23, 2017:  3 points 
•	Spring Parent Academy (serve as volunteer minimum 3 hours) – March 10, 2018:  3 points 	

*Dates/times subject to change.  Complete schedule will be provided at Orientation.
**Early Release Day – Students will ride bus from home school to RCA.  
Parents will pick-up students at RCA.	
Applicant and Parent/Guardian Commitment
To graduate from Rockdale Youth Leadership, a student is expected to earn a minimum of 40 points by attending scheduled RYL sessions or make-up sessions as listed above.  Participation in the community service day in April 2018 is required to graduate.  Upon acceptance into RYL, the $75 commitment fee is due to be paid at the Orientation Program on Tuesday, September 26.  Partial and full scholarships are available based on need.  RYL will not turn away any accepted student based on ability to pay; however, payment/scholarship application must be finalized before the Rockdale Youth Leadership Retreat on October 12.  All fees must be paid by Monday, October 23, 2017.

I understand the purpose of Rockdale Youth Leadership (RYL). If selected, I will commit my time and resources to complete the program. Even though emergencies may arise, I understand that if I miss three regularly scheduled sessions, I may be asked to withdraw from the program. By signing this application, both my parent/guardian and I state that we understand and accept this commitment and will honor it.

Applicant Signature _____________________________________ Date_______________

Parent/Guardian Signature ________________________________ Date_______________
(If submitting application electronically, application can be signed at Orientation.)
Rockdale Youth Leadership 2017-2018
Parental Consent and Medical Release Form

Student Name:       			Age:       		Date of Birth:      

Gender:       				Home Phone:      

Address:      

City, State, Zip:      

School:      

Parent / Guardian Names:      

Parent / Guardian Home Phone:      

Parent / Guardian Work Phone:      

Emergency Contact: (Please list two adults other than parents who may be contacted in case of emergency.)

Name:       					Phone(s):      

Name:       					Phone(s):      

Medical Information

Name of Physician:       			Phone:      

Date of Last Physical Examination:       				Drug Allergies:      

Other Allergies:      

Describe any physical limitations:      

Describe any recent illness or injury:      

Is there a history of:    
Heart condition      	Yes        No  
Diabetes		Yes        No   
Asthma		Yes        No    
Epilepsy 		Yes        No 
Rheumatic fever	Yes        No 
Other (list any)      

Rockdale Youth Leadership 2017-2018
Parent Consent and Medical Release Form (cont.)

To Whom It May Concern:

The undersigned do (does) hereby give permission for our (my) child,       
to attend and participate in activities sponsored by Rockdale Youth Leadership for the 2017-2018 year.

We (I) authorize an adult, in whose care the minor has been entrusted by Rockdale Youth Leadership, to consent, in case of emergency, to any X-Ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any duly licensed physician or dentist, whether such diagnosis or treatment is rendered at the office of said physician or dentist or at a licensed hospital.

The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

	Hospital Insurance:  Yes        No 

	Insurance Company:       

	Policy No:       

The undersigned do (does) also hereby give permission for our (my) child to ride any vehicle designated by the adult whose care the minor has been entrusted while attending and participating in activities sponsored by Rockdale Youth Leadership. 
(If submitting application electronically, application can be signed at Orientation.)

____________________________________
Participant                           	 Date

____________________________________
Father (or Guardian)          	 Date

____________________________________
Mother (or Guardian)          	 Date

Before returning application:
•	Complete all sections of the application. 
•	Review the calendar and session schedule to meet attendance requirement.  
•	Answer each short-answer question.  
•	Have the Reference form completed by a Teacher, Advisor, Leader or Coach. 
•	Have the Counselor Reference form completed by a Counselor.
•	Complete the Parental Consent and Medical Release Forms.
•	Review and include all signatures
•	Submit your application by FRIDAY, SEPTEMBER 1, 2017.  

For more information, please contact your RYL School Contact:
•	Nancy Turney – Heritage High School	
•	Lauren Lewin – Rockdale Magnet School
•	Karen Hardy – Rockdale County High School	
•	Tami Maddox – Rockdale Career Academy
•	Cecile Cooper – Salem High School

Application Submission
The RYL application deadline is FRIDAY, SEPTEMBER 1, 2017.
Applications may be submitted electronically OR as a hard copy.
•	Electronic copy:  To submit an electronic copy of the application, complete the form, save it with your name in the file name, and e-mail it to DJ Youngblood at dyoungblood@rockdale.k12.ga.us.
•	Hard copy:  To submit a hard copy of the application, complete the form and return it to:
DJ Youngblood, RMSST, 930 Rowland Road, Conyers, Georgia 30012. Must be received by the deadline. 

Be sure that the teacher reference is sent in a timely manner so the person 
making the reference can complete and return the form by the deadline.

Questions may be directed to:
Tami Maddox, RCPS Work-Based Learning & Youth Apprenticeship Coordinator
Rockdale Career Academy, 1064 Culpepper Drive, Conyers, GA 30094
678-584-3080 (office)    tmaddox@rockdale.k12.ga.us