Youth Leader Application

Youth Leader Application
The Caffee, Caffee, & Associates Public Health Foundation, Inc. (“CCA PHF”) is a tax-exempt 501(C) 3 nonprofit organization founded in 1998 to address public health, cultural, social, and environmental issues in disparate populations and communities. In May 2019, CCA PHF was awarded a grant to empower at-risk youth to reject tobacco and create the first tobacco-free generation for the state of Mississippi. One of the requirements for this grant is to employ students from the ages of 15-18 in the position of Youth Leaders to facilitate age-appropriate activities for at-risk teens.

The CCA PHF has established criteria for the Youth Leader position. Students will be chosen by the following information:
1. Minimum GPA: 2.0 or above
2. Be able to lead a group
3. Must participate in at least one other extracurricular activity such as Beta Club, Drama Club, Scholar program, etc.
4. Tech-savvy
5. Positive Attitude
6. Recommendation letter from a teacher or school counselor
7. 30-second video displaying presentation skills
8. 200 word typed essay (Choose only one topic)
  - Explain the Cause and Effect of smoking cigarettes.
  - Should Tobacco advertising be banned?
  - Explain what is Tobacco Prevention and why it is needed?
  - Completed application
The completed application and recommendation letter must be received by Friday, August 23, 2024.

5317 Old Hwy 11, Ste 11
Hattiesburg, MS 39402

Phone: 601-336-7212
Fax: 601-602-4227
www.butobaccofree.com

“The BU program is funded by a grant from the Mississippi State Department of Health -Office of Tobacco Control.”

Emergency Contact Information
Parent 1 / Guardian 1*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Parent 2 / Guardian 2

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com

I give permission for my child (named in the Youth Personal Information Section of this form) to participate in the Caffee, Caffee & Associates Public Health Foundation Youth Tobacco Prevention Program. Following events and activities associated with the Youth Tobacco Prevention Program, transportation may be provided by Caffee, Caffee & Associates Public Health Foundation.*

YesNo
I hereby grant permission to Caffee, Caffee & Associates Public Health Foundation to use photographs and/or video of me taken during and for activities related to the Youth Tobacco & Vape Prevention Program in publications, news releases, online, and in other communications related to the mission of Caffee, Caffee & Associates Public Health Foundation Youth Tobacco & Vape Prevention Program.*

YesNo
I grant Caffee, Caffee & Associates Public Health Foundation the right to use drawings, slogans, videos, songs or other intellectual property that was created by me for the purpose of fulfilling the mission of Caffee, Caffee & Associates Public Health Foundation, Youth Tobacco & Vape Prevention Program, and I agree that any materials submitted to the Caffee, Caffee & Associates Public Health Foundation for the purpose of the Youth Tobacco & Vape Prevention Program is now the property of Caffee, Caffee & Associates Public Health Foundation.*

YesNo
Please type the name of the Parent or Legal Guardian that is going to sign below.*
Signature of Parent or Legal Guardian*

Clear
Date*
Should be Empty:

	Start Time	End Time	Class (Homeroom, Lunch, Advisory, etc.)
1st Period
2nd Period
3rd Period
4th Period
5th Period
6th Period
7th Period

	Start Time	End Time	Class (Homeroom, Lunch, Advisory, etc.)
Block A
Block B
Block C
Block D
Block E
Block F
Block G

Youth Leader Application

Youth Leader Personal Information

School Information

Emergency Contact Information