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. February 6-8, 2020 in Berkeley, CA
Adult Advisor Name *
Your answer
Title
Your answer
Agency/ Organization *
Your answer
Gender
Your answer
Address *
Your answer
City/ State/ Zip *
Your answer
Work Phone *
Your answer
Cell Phone *
Your answer
Email *
Your answer
Date of Birth *
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Applications for the following youth have been submitted: (Please list names of 4 youth + 1 alternate) *
Your answer
Where did you learn about the Academy? *
Your answer
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.
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Required
I understand that limited travel stipends are available. Our team: *
Estimated Travel Expenses: *
Your answer
Alternate Adult Advisor Name *
Your answer
Title
Your answer
Agency/Organization *
Your answer
Gender
Your answer
Address *
Your answer
City/State/Zip *
Your answer
Phone *
Your answer
Email *
Your answer
Date of Birth *
MM
/
DD
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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: *
Your answer
Please submit all forms by October 31, 2019
If you have any questions or concerns please email joselyn@berkeley.edu
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