Empowered Youth Coalition Application
What is Empowered Youth?

Empowered Youth is a brand new High School Prevention Coalition created just for Johnson County. It will be a youth-led decision-making coalition that works to prevent underage alcohol, tobacco, vaping, and other drug use. We are looking for teens who can be leaders and help their peers make healthy choices and stay substance free.

Who Should Apply?
Youth who can reply "YES" to all the following criteria:

*I attend High School (or Home-school) in Johnson County
*I am concerned about peer alcohol, tobacco, vaping, and other drug use in my school and community
*I want to be part of a county wide youth lead organization
*I am prepared to learn new skills and how to be a civically engaged community member
*I am willing to help plan and participate in activities in my school and community
*If selected for Empowered Youth, I will participate in 2 monthly meetings (one in person and one conference call/online meeting, dates TBD and flexibility to work with your schedule)
*If selected for Empowered Youth, I will participate in one leadership training or retreat during the 2019-2020 school year(dates TBD)

What will Empowered Youth do?

-Empowered Youth members will be representatives for their respective high schools and communities. The area of focus for the 2019-2020 school year will be on underage alcohol use and vaping/tobacco use.

-Members will participate in 1 monthly conference call/online meeting AND 1 monthly in person meeting. (Locations TBD but will be in Johnson County)

-Members will plan and execute activities, projects, and strategies throughout the year to bring awareness and education about prevention to each of their schools and Johnson County communities.

-Members will be trained in prevention best practices throughout the year and invited to participate in leadership training. Members will be invited to take part in Empowered Youth Leadership Retreat (date TBD).

-Members may also have the opportunity to attend special events at the statehouse and/or other legislative hearings pertaining to youth substance use.

Empowered Youth Application Checklist:
1. Online Application
2. Membership Agreement (includes Parental Consent)
3. 1 (non-relative) adult reference (provide contact information in application)

Application open August 30,2019 through October 21, 2019.

Plan Ahead: FIRST CONFERENCE CALL/ONLINE MEETING will be on Thursday OCTOBER 24, 2019 @ 6PM.

Questions?
Contact Miranda Broomfield
Miranda@upstreamprevention.org
317-372-8937



Email address *
Tell Us About Yourself
Name *
Your answer
Address *
Your answer
Email *
Your answer
Phone Number *
Your answer
What grade are you currently in for the 2019-2020 school year? *
High School you currently attend *
Date of Birth *
MM
/
DD
/
YYYY
Which of the following is your preferred method of communication? *
Which 1 or 2 Social Networking Sites do you use most often? *
Why do you want to be a member of Empowered Youth? *
Your answer
What do you believe is the biggest issue in your school or community surrounding any type of youth substance us (alcohol, tobacco, vaping, other drugs)? *
Your answer
Describe any experience you've had with youth, prevention, advocacy, or leadership groups/roles. *
Your answer
Describe a time in your life where you showed leadership initiative *
Your answer
What do you think are good ways to get more adults involved in preventing underage alcohol and substance use? *
Your answer
What other school or community organizations/activities are you currently involved with? *
Your answer
Describe how you work in a group *
Your answer
Is there any other information that you feel is important for us to know/consider when reviewing your application?
Your answer
I understand that, if selected to be part of Empowered Youth Coalition, I am committing to all of the following: *
Required
I understand that as a member of Empowered Youth Coalition I will be a leader and example to both adults and other youth and I agree to the following: *
Required
Read Acknowledgement: *
Required
Adult Recommendations
Only one reference is required, but you may add up to two. Recommendations are considered confidential information.
Reference: The name of the person (non-relative) who will complete a RECOMMENDATION QUESTIONNAIRE on my behalf is: *
Your answer
Relationship to Applicant *
Your answer
Place of Employment
Your answer
Job Title
Your answer
City/Town *
Your answer
State *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Reference 2 (optional): The name of the second person (non-relative) who will complete a RECOMMENDATION QUESTIONNAIRE on my behalf is:
Your answer
Relationship to Applicant
Your answer
Place of Employment
Your answer
Job Title
Your answer
City/Town
Your answer
State
Your answer
Email Address
Your answer
Phone Number
Your answer
I, the undersigned applicant, have carefully read and completed the Empowered Youth Coalition Application and Agreement and the Recommendation Acknowledgement myself and will abide by them of my own free will. I hereby release Empowered Youth Coalition, Empower Johnson County, Upstream Prevention, and their respective offices, directors, agents, employees, and representatives from any and all claims and causes of actions arising out of my participation in the Empowered Youth Coalition. I understand that my Empowered Youth Coalition membership is a privilege and agree to abide by all of the above and related decisions with regard to dismissal from the program. I certify that I am the person accessing this webpage and submitting this application. By checking these boxes and typing my name below, I certify that all information on this form is true and correct to the best of my knowledge and agree that this is to serve as my electronic signature. Please type your name in the box below to consent to the above Electronic Signature Agreement. *
Your answer
Parent/Legal Guardian Information
Full Name of Parent/Legal Guardian *
Your answer
Mailing Address *
Your answer
Primary Phone Number *
Your answer
Secondary Phone Number *
Your answer
Email Address *
Your answer
I, the undersigned parent/legal guardian, have read and fully understand the above terms of the Empowered Youth Coalition Application, Empowered Youth Coalition Agreement, and the Parental Consent Agreement and will abide by them of my own free will. I hereby release Empowered Youth Coalition, Empower Johnson County, Upstream Prevention, and their respective offices, directors, agents, employees, and representatives from any and all claims and causes of actions arising out of my participation in the Empowered Youth Coalition. I understand that my child's Empowered Youth Coalition membership is a privilege and agree to abide by all of the above and related decisions with regard to dismissal from the program. I certify that I am the person accessing this webpage and submitting this application. By checking these boxes and typing my name below, I certify that all information on this form is true and correct to the best of my knowledge and agree that this is to serve as my electronic signature. Please type your name in the box below to consent to the above Electronic Signature Agreement. *
Your answer
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