YWLA Adult Recommendation/Commitment Form
The Young Worker Leadership Academy. Presented by LOHP-UC Berkeley, LOSH-UCLA and the Commission on Health & Safety and Workers' Compensation. The 2021 YWLA will be held virtually from Thursday, March 4, through Saturday, March 6th, 2021.
Adult Advisor Name *
Title
Agency/ Organization *
Gender
Address *
City/ State/ Zip *
Work Phone *
Cell Phone *
Email *
Date of Birth *
MM
/
DD
/
YYYY
Applications for the following youth have been submitted: (Please list names of 4 youth + 1 alternate) *
Where did you learn about the Academy? *
Attending the Academy
As an adult recommending a youth team to attend the Young Worker Leadership Academy, please check off the boxes below acknowledging that you have reviewed the following items and that you and the youth understand the requirements and benefits of participating in the Academy. An adult sponsor must agree to accompany the team and to support them in planning and conducting their team project.
*
Required
I understand that limited travel stipends are available. Our team: *
Estimated Travel Expenses: *
Alternate Adult Advisor Name *
Title
Agency/Organization *
Gender
Address *
City/State/Zip *
Phone *
Email *
Date of Birth *
MM
/
DD
/
YYYY
Statement
Please make a brief statement about the team of youth you are recommending the Academy and why they will be valuable and effective contributors to your community in promoting workplace health and safety through a team project. Please briefly describe your role and interest in this Academy and how your organization and staff will support the team you are recommending e.g. school/ work, schedules, meeting space, etc.
Please add your statement below: *
Please submit all forms by 5pm on December 4, 2020.
If you have any questions or concerns please email elisha.jaeke@berkeley.edu.
Submit
Never submit passwords through Google Forms.
This form was created inside of UC Berkeley. Report Abuse