CAYLI Application

CAYLI Application

Community Action's Mission is to improve the quality of life for families through education, training, comprehensive services and advocacy. Tell us how we can better serve you. Please complete this form below with all necessary information pertaining to your house hold.

Student Information:

* Indicates required field

Name *

First

Last

Date of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Current Grade *

School *

Homeroom Teacher *

Cell Number *

Parent/Guardian Information:

Name *

First

Last

Relationship *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Cell or Work Number *

Alternate Number *

Email *

It is a requirement that each student submit a four paragraph essay in which they will express the value of leadership, their reason for wanting to be a part of the CAYLI program and expected outcome.

Please submit essay below.

Essay *

Submit