Youth In Action Program Application
This is a youth leadership program that focuses on social justice, being active in your community, and peer education. You will learn about community health, digital media arts, and advocating for student centered learning in schools. There are also opportunities to receive school credit for participation as well as community service hours.

A mandatory Wilderness Retreat will take place August 14th -17th 2017.
Program will take place on Wednesdays starting in September 2017 - June 2018. Please make sure your are committed and able to attend programming for the year.

Application deadline - Friday, June 16, 2017
Acceptance announcement - Friday, June 23, 2017

Name
First & Last
Your answer
Age
Your answer
Sex
Grade
Please enter the grade you will be in starting September 2017
Your answer
Birthdate
MM
/
DD
/
YYYY
School Name
Your answer
Home Address
Street, City, & Zip Code
Your answer
Youth Cell Number
Your answer
Youth E-mail
Your answer
Youth's Ethnicity
Your answer
Parent/ Guardian Name
Your answer
Parent/ Guardian Phone Number
Your answer
Language(s) Spoken At Home
Your answer
Will you receive a free bus pass?
Other programs/ sports you are participating in?
Your answer
How did you hear about YIA?
If you heard from a friend/ family member please specify their name
Your answer
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