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2. Application Form
4. First Name*
5. Last Name*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
15. Email Address*
17. Name of Parent/Legal Guardian*
19. Emergency Contact Information
21. Name of Emergency Contact*
23. Relation*
24. Phone Number*
26. Email*
28. What District do you live in?*

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    3. 3
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    5. 5
    6. 6
30. How did you hear about Las Cruces Developing Leaders Academy?*
32. Do you need any accommodations for accessibility? If yes, please list.*
34. Why do you want to participate in this program?*
36. Describe your present and past volunteer experience in Las Cruces.*
38. What do you expect to learn from the Las Cruces Developing Leaders Academy?*
40. Is the information you provided in this application true and accurate?*
42. How long have you been living in Las Cruces (years)?*
43. Your Gender*
45. Age?*
46. Race/Ethnicity?*
48. Media/Photo Release: Photographs/Video may be taken during the developing Leaders Academy. They City of Las Cruces may utilize these photos/videos for brochures, presentations, social media or newsletters.
50. Parent/Legal Guardian Consent
52. Name Parent/Legal Guardian*
54. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
56. Electronic Signature*
57. Date/Time*
    Date/Time

    Date/Time
59. Statement of Committment
61. The purpose of Developing Leaders Academy is for High School students to gain knowledge about how local government works and the resources it provides to improve the community's quality of life.
63. I commit to attend all five (5) sessions.*

    1. Yes
65. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
67. Electronic Signature*
68. Date/Time*
    Date/Time

    Date/Time
Leave This Blank:


70. 1. Receive an email copy of this form.
71. Email address

    This field is not part of the form submission.

72. Submit

* indicates a required field