The 84 Statewide Leadership Team Application

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The 84 Statewide Leadership Team Application k:\the 84 movement fy14\kbd 2014\photos\jpeg\011_kickbutts2014_011.jpg

Dear applicant,

Woohoo! You’re interested in the Statewide Leadership Team (or SLT, as we call it)! So, you may be asking yourself, “What am I getting myself into?” Well, here’s the scoop.


If you’re looking for a way to protest the tobacco industry, create change, build leadership skills, and spread The 84 to other youth across the state, this group is for you. Doing all these things does require a commitment, though, so we want to make sure we pick the right candidates. We accept 20 youth each year to be a part of this program – one that will surely increase your confidence, make you more connected to your community, and potentially change your life for the better. k:\the 84 movement fy14\kbd 2014\photos\jpeg\022_kickbutts2014_022.jpg

Here’s what the typical SLT member does:

  • Acts as media spokespeople for interviews

  • Represents The 84 at statewide tobacco meetings

  • Prepares and delivers presentations to peers or adults

  • Leads event planning for the Youth Power Summit and Kick Butts Day

  • Recruits new Chapters to the Movement

  • Speaks at public events c:\users\ccaminiti\desktop\kickbutts022.jpg

Don’t worry – we give you training along the way and we’re called a TEAM for a reason – we do it all together!

Here’s what we are looking for and what we expect from you:c:\users\ccaminiti\desktop\005_youthpower_005.jpg

  • High school freshman, sophomore, or junior

  • Someone who’s not involved in a lot of other extracurriculars but looking to build leadership skills

  • Someone who’s organized and responsive whenever we email or text

  • Someone who is passionate about fighting Big Tobacco


We also give preference to those who live in communities with high smoking rates and/or high densities of tobacco retailers. Finally, we give preference to people of color and to LGBTQ youth because the tobacco industry targets those groups more than others. And we’re not okay with that!

So what are you waiting for? We can’t wait to see your application. Just follow the easy steps below.

Step 1 – Fill out the Application

Name: Click here to enter text. Chapter: Click here to enter text.

Grade: Click here to enter text. Birthday (MM/DD/YY): Click here to enter text. High School: Click here to enter text.

Phone Number: Click here to enter text.

Email: Click here to enter text.

Home address: Click here to enter text.

Parent/Guardian name: Click here to enter text.

Parent/Guardian e-mail:Click here to enter text.

Parent/Guardian number: Click here to enter text.

Emergency Contact Name: Click here to enter text. Emergency Contact Number: Click here to enter text.

Note: we will be contacting your parent/guardian and your Chapter advisor for a reference check. If you would rather us contact another adult who is not your parent/guardian, please provide their information (name, e-mail, phone number) below:

Step 2 – Answer these questions

Please answer questions completely in 100-250 words by typing them onto this document.

  1. Describe your involvement with your 84 Chapter (how long you’ve been involved, activities you’ve participated in, relationship to other members and advisor).

  2. Why are you passionate about tobacco prevention in your community?

  3. How will you impact your community and the state by being a part of the Leadership Team?

  4. Give three adjectives to describe your personality and explain how those qualities will help you lead.

  5. What other after school activities are you actively engaged in?

From the list below, PUT AN ASTERISK (*) next to three skills that you feel you possess and BOLD three skills that you would like to strengthen by being a part of the Statewide Leadership Team.

Script writing

Presentation skills

Event planning

Public speaking

College preparedness

Evaluation skills


Verbal communication

Project management


Ability to engage

Volunteer recruitment

Advocacy skills

Conversational skills

Expressing opinion

Facilitation skills

Social media

Website development

What is your most preferred method of communication? From the list below, please number 1-5 with 1 being the most preferred way of communicating and 5 being the least preferred.

___ Phone call ___ Text ___ Email ____ Facebook Group/Message ___ Group Text

Optional: Please check the following demographics that you identify with. They will remain anonymous and are only used to collect data.


☐Hispanic or Latino

☐Non-Hispanic or Latino

☐Other: ________





☐Other: ________


☐Heterosexual (straight)

☐Gay or lesbian




☐Other: _________



☐Black or African American


☐Pacific Islander or American Indian or Alaska



☐Other: _______

Step 3 – Submit your application

Please send the completed application via email to or via mail to:

Health Resources in Action

Cameron Fear

95 Berkeley Street, Suite 208

Boston, MA 02116

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