YLC 2025 Application – Capital Black Chamber of Commerce

Name *

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Last

Email *

Birthday

Age

Address

Address Line 1

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Zip Code

Do you have reliable transportation?

Phone

What is your best form of communication?

Frequently used Social Media

School

Grade Point Average (GPA)

What is your college major or interest?

What major or career are you interested in?

How did you hear about YLC?

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Describe your school / community involvement

Student Signature

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Today’s Date

Parent or Guardian Signature

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Relationship

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Emergency Contact Phone Number

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