Complete the application form and use submit button below. The information submitted must be your own work, and not completed by someone else.

If you have any questions, please email youth@phoenix.gov or call (602) 495-0314 during normal business hours.

Deadline: December 11, 2009 at 5pm MST.

To be considered for the program you must reside within city of Phoenix boundaries.

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General Information

First Name:*
Last Name:*
Middle Initial:*
Male Female
Address:*
City:*
State:*
Zip code:*
Home Phone:
Cell Phone:
Best Time to Call:
Fax:
E-mail address:*

School:

Expected Graduation Year:* Birth date:*

Please identify your Council District and Phoenix City Councilmember.

1-Thelda Williams	3-Bill Gates	5-Claude Mattox	7-Michael Nowakowski
2-Peggy Neely	4-Tom Simplot	6-Sal DiCiccio	8-Michael Johnson

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Personal Statement

You write no more than 750 words answering the following questions:*

• How have you been involved in the Phoenix community and what impact have you had?

• What areas of your life demonstrate your commitment to excellence? This may include work, school, sports, family, or obstacles you have overcome.

• Which one teacher has had the greatest impact on your life? Please explain. (Include their name and indicate the school in which they taught or currently teach, if known.)

• What do you see yourself doing ten years from now, and how will you achieve those goals?

Words remaining:

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Referred By:
Teacher
Counselor
Other
Friend, who?

I attest that this application was written in its entirety by me. * Yes No

* Required fields

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