2017-2018 COYAC Membership Application
The Colorado Youth Advisory Council does not discriminate against any member or potential member on the basis of race, family income, gender, ethnicity, religion, sexual orientation or disability.

Please note that these are the meeting dates for the upcoming term and check to ensure your availability:
Saturday, October 21, 2017
Saturday, November 18, 2017
Saturday/Sunday, March 3/4, 2018 (tentative)
Wednesday, April 4, 2018 (tentative)

APPLICANT INFORMATION
Name
First and last name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Gender
Primary Phone Number
Your answer
Secondary Phone Number (optional)
Your answer
Address (if you have a separate mailing address please include that as well)
Your answer
Primary Email Address
Your answer
Secondary Email Address
Your answer
Colorado State Senate District (You can find it at: leg.colorado.gov/find-my-legislator)
Your answer
My State Senator is . . .
Your answer
My State Representative is . . .
Your answer
COYAC members serve for two years. Please affirm that you are able to serve a two-year term on the Council by answering "yes" below:
As a member of COYAC, you will be required to respond to inquiries from Engaged Public and your fellow council members in a timely manner. If you are unresponsive, you may be eligible for removal from the council. Therefore, please indicate the two best ways to contact you.
COYAC strives to reflect the diversity of youth across Colorado and actively recruits students from all parts of the state as well as from all racial and ethnic backgrounds. By providing the following information you will assist the council in reaching this goal. Please indicate your race/ethnicity.
EDUCATION INFORMATION
Current Grade (2017-2018 school year)
Current School
Your answer
School Address
Your answer
School Contact Person
Your answer
School Contact Phone Number
Your answer
School Contact Email Address
Your answer
PARENT/GUARDIAN CONTACT INFORMATION
Primary Parent/Guardian Name
Your answer
Primary Parent/Guardian Address
Your answer
Primary Parent/Guardian Phone Number
If applicable, please list multiple phone numbers, indicating home, mobile or work number.
Your answer
Primary Parent/Guardian Email Address
Your answer
Secondary Parent/Guardian Name
Your answer
Secondary Parent/Guardian Address
Your answer
Secondary Parent/Guardian Phone Number
If applicable, please list multiple phone numbers, indicating home, mobile or work number.
Your answer
Secondary Parent/Guardian Email Address
Your answer
EMERGENCY CONTACT PERSON
Emergency Contact Name
Your answer
Emergency Contact Phone Number
Your answer
Emergency Contact Person's Relationship to You
Your answer
ESSAY QUESTIONS
Please limit your answers to 250 words. You may want to compose your answer in a Word document and then cut and paste into this section.
What are some of the important issues that young people face in your community?
Your answer
Please describe the activities that you are involved with both in and out of school.
Your answer
Why do you want to serve as a member of the Colorado Youth Advisory Council?
Your answer
What skills, talents and/or unique perspectives will you bring to the Council?
Your answer
SIGNATURE
My typed signature verifies the authenticity of the information provided herein. I understand that the information provided in this application will be used to evaluate my eligibility to serve on the Colorado Youth Advisory Council. I also understand that submitting an application does not guarantee a position on the Council. I further understand that Council positions are two-year commitments. If accepted, I agree to serve the full term of my appointment.
Signature of Applicant
Your answer
Date Submitted
MM
/
DD
/
YYYY
QUESTIONS?
Please contact Cheryl Fleetwood, COYAC Director, at (303) 877-0211 or cheryl@engagedpublic.com.
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