Albert Schweitzer's Leadership for Life

Nurturing The Next Generation of Leaders

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Albert Schweitzer's Leadership for Life Application Form
Personal Details :
Name :
Sex : MaleFemale
Date of Birth : / /
mm /  dd  /  yyyy
Address :
Tel : (Home)
E-mail :
Name of Participant School :
City of Residence :
State of Residence :
Country of Residence :
Country of Origin :
Participant Passport Number :
Name of Parent/Legal Guardian :
Where to reach Parent/Legal Guardian in case of emergency :
Daytime Phone :
Mobile Phone :
Evening Phone :
Email Address :
Other :
Name of another responsible adult :
Relationship to participant :
Contact Numbers :
Email Address :
Conference T-shirt Size : SMLXLXXL
Leadership Qualities:
Why would you like the opportunity to participate in the Albert Schweitzer Leadership for Life program?
What leadership skills do you think you have?
Please give an example of how you have demonstrated leadership
During the leadership program you will develop a leadership goal. Please give details of a goal you would like to achieve and the steps you would take to do so.
Parent/Guardian Consent :
I give permission for the above named to apply to attend the Albert Schweitzer's Leadership for Life Programme from (Waiting to confirm dates Saturday, July 22nd to Sunday, July 30th, 2017) in NUI, Maynooth, Co. Kildare.
Photograph and Film Footage Release Statement :
I give my consent to the ICCUSA Foundation to publish and use photographs and film footage taken of my son/daughter (as named above) at the Albert Schweitzer's Leadership for Life Conference 2017. All materials become the property of ASLFL and may be used, without further permission, for publicity purposes including print, television or web based sources. If you have any queries in relation to the above condition, please contact ASLFL at: to discuss the matter.
Notes on completing the form :
  • Please ensure that you complete all sections of the form carefully.
  • Please ensure you include your full address as we will be sending you further information by email.
  • Please include a contact number as we may need to contact you directly about your application.
  • Selection is based on the information you provide on the form, so take the time to think about your answers.
  • Late applications will not be accepted so submit early to avoid disappointment.
  • Ensure that you your parent/guardian sign the form. Applications will be returned if they are not signed.
Completed forms must be returned on or before Friday, March 17, 2017. *However, registration may close sooner if we exceed the amount of spaces for the conference.
Contact Information:
Albert Schweitzer Leadership for Life Foundation
219 South Street – Suite 203
New Providence, New Jersey 07974

“Search and see if there is not some place where you may invest your humanity.”
~Albert Schweitzer

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