Youth Advisory Initiative Application

Contact Information:

Name: _____________________________________ DOB: __________________ Age: ______

Home Address: _________________________________________________________________

Mailing Address: _______________________________________________________________

City: ________________ State: ______ Zip Code: __________ Home Phone: ______________

Cell Phone: ________________ E-mail Address: ______________________________________

Gender:

What is your preferred gender? ⬜ Male   ⬜ Female  ⬜ Other: _______________________

Employment:

Are you employed?  ⬜ Yes        ⬜ No

        If yes, please check: ⬜ Full-time        ⬜ Part-time

Education:

School:  _________________________________________________

Do you attend school on a regular basis? ⬜ Yes        ⬜ No

        If yes, please check: ⬜ Full-time        ⬜ Part-time

If no, explain: ___________________________________________________________

Name of guidance counselor: _________________________________________________

Current grade: ___________                Current GPA: _____________

Do you participate in any after-school activities (i.e. sports or clubs) ⬜ Yes     ⬜ No

If yes, which activities?

Legal History:

Have you had any prior legal violations or involvement with a diversion program? ⬜ Yes   ⬜ No

If yes, please explain:

Leadership:

Tell us a bit about any experience you have in being in a leadership position:

Why do you want to join the Youth Advisory Initiative?

Availability:

When would you be available to participate in Youth Advisory meetings and activities?

⬜ Weekdays, daytime        ⬜ Weekdays, evening    

⬜ Weekends, daytime        ⬜ Weekends, evening                ⬜ Other: ___________

Acknowledgement:

By signing this document, you acknowledge that your application and all its contents will be subject to review by a Board composed of community members. This Board will evaluate your eligibility for acceptance into the Youth Advisory Initiative.

Youth Signed: ___________________________________ Date: ________________________

Parent Signature: _________________________________ Date: ________________________