North River Youth Coalition Application

2021-2022 Application

By, With & For Youth
We're so happy you are taking the time to apply to be one of our youth ambassadors! We recommend that you look over all of the questions before beginning the application.

Take your time & good luck!
I have Read and Understand the above instructions. *

Yes, I have
If selected, you may be asked for further documentation to support the data you provide. Likewise, all correspondence will be generated from the personal information submitted below. So, please use proper spelling, capitalization and punctuation.
I. Personal Data:

Tell us about yourself
Full Name *

First Name Last Name
Mobile No. : *

Area Code Phone Number
E-mail : *
Where the confirmation will be send to
Home Address : *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Are you between the ages of 14-18? *

Yes, I am. No, I am not.
Optional Information:

Information regarding gender, ethnic origin and race are optional.
Gender:

Male Female Other Prefer not to answer
Ethnic Origin:

Hispanic Non-Hispanic Prefer not to answer
Race? (Choose all that apply):

White Black, African American or Caribbean Asian American Indian or Alaskan Native Hawaiian or Other Pacific Islander Other Prefer not to answer
I. Parent/Guardian Data:
Full Name *

First Name Last Name
Home Address : *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Contact Phone No. : *

Area Code Phone Number
E-mail :
Where the confirmation will be send to
Parent/Guardian Signature

Media Release Permission
By signing (typing your legal name) in the space below, you are agreeing to and giving consent that North River Prevention Partners (NRPP) and their respective affiliates, subsidiaries, licensees, successors and assigns may use any video, still photo, or voice recordings taken of your son/daughter/ward during his/her time as a NRYC ambassador, or any reproduction thereof, in any form, style, or color, or media, together with any writing and/or other advertising and/or publicity material in connection therewith, including the use of his/her name as they may select. NRPP shall be the exclusive owner of such taping, photography, and recording with the right, throughout the world, an unlimited number of times in perpetuity, to copyright, to use, and to license others to use, in any manner, all or any portion thereof or of a reproduction thereof in connection with NRPP or otherwise.
E-Signature: *
Full Legal Name
II. High School Information:
Current School Attending: *
Status at the time of application: *

I am a senior I am a junior I am a sophomore I am a freshman I am an 8th grader
Most recent GPA: *
If under 2.5, please explain why in your essay at the bottom of this application.
Please list any honors or awards:
VI. Extras:
Please list current and past extra-curricular activities with your school, church or within the community: *

0/300
Please tell us about your hobbies, interests or passions: *

0/300
Do you currently have a job?

Yes No
Have you ever had a job?

Yes No
If yes, name of your current or previous employer:
Meeting Information
Meetings are in-person, usually twice a month from 6:30-7:30pm, either in Palmetto or Ellenton. Will you be able to attend at least once a month? *

Yes, once a month Yes, twice a month I can only attend virtual meetings
Will you be able to download and use the Band App? *

Yes No
VII. Why do You Want to Become a North River Youth Ambassador?

Short essay
In at least 300 words, please explain why you want to become a North River Youth Ambassador and your thoughts on being part of a coalition that promotes an alcohol, drug & nicotine free lifestyle for youth.

Additionally, if your GPA is under 2.5, in a separate paragraph, please explain why.
Answer:

0/500
VIII. Applicant's E-Signature
By signing (typing your legal name) in the space below, you are certifying that all information is correct and that you are the person completing this application.

Additionally, by signing you are agreeing to and giving consent that North River Prevention Partners (NRPP) and their respective affiliates, subsidiaries, licensees, successors and assigns may use any video, still photo, or voice recordings taken of me during my time as a NRYC ambassador, or any reproduction thereof, in any form, style, or color, or media, together with any writing and/or other advertising and/or publicity material in connection therewith, including the use of my name as they may select. NRPP shall be the exclusive owner of such taping, photography, and recording with the right, throughout the world, an unlimited number of times in perpetuity, to copyright, to use, and to license others to use, in any manner, all or any portion thereof or of a reproduction thereof in connection with NRPP or otherwise.

When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.

Thank you for your submission.
E-Signature: *
Your Full Legal Name
North River Youth Coalition

By, With & For Youth
North River Prevention Partners is committed to equal opportunity in employment and education. We do not discriminate in any program or activity on the basis of race, color, religion, gender, age, national origin, disability, or any other protected class.
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2021-2022 Application

I. Personal Data:

I. Parent/Guardian Data:

Parent/Guardian Signature

II. High School Information:

VI. Extras:

Meeting Information

VII. Why do You Want to Become a North River Youth Ambassador?

VIII. Applicant's E-Signature

North River Youth Coalition