Statewide YAC Interest Form

1
What is your first and last name?* This field is required.
2
Do you have any other preferred names or nicknames we should use for you instead of what you listed above?
3
What are your pronouns?* This field is required.
she/her
he/him
they/them
she/they
he/they
any pronouns
Other
4
What is your birth date? * This field is required.Note: We can only accept applicants who will be in high school during the program year (2023-2024)
Date
Month
Day
Year
5
What is your email address?* This field is required.
6
What is your phone number?
Area Code
Phone Number
7
How can we best connect with you?* This field is required.
I respond best to texts!
I respond best to emails!
8
Which school will you be attending in the 2025-2026 school year?* This field is required.
9
What grade are you in/going in to?* This field is required.
9th
10th
11th
12th
10
Where do you live?* This field is required.
11
Parent/Guardian InformationPlease provide the necessary contact information for your parent/guardian! If you are unable to provide this information or are hesitant about your parent/guardian knowing you are interested in this opportunity, reach out to Kanyn at kanyn.doan@ppmi.org to talk through potential next steps!
First name
Last name
Phone number
Email
12
PPMI Statewide YAC Representatives are *required to attend monthly meetings* beginning in October 2025 that last for one and a half hours. YAC Representatives are *paid a stipend* for their active and continuous participation and engagement with the program. Active participation in the monthly meetings are a requirement in continuing to be a YAC Representative. Is this a requirement you believe you can uphold?* This field is required.
Yes
No
Maybe
13
Why are you interested in representing your community in PPMI's Youth Advisory Council?
14
Do you have any questions about PPMI's Youth Advisory Council?
15
Do you have any accessibility needs that the YAC Coordinators should be aware of?
16
Thank you SO much for your interest in representing your community in Planned Parenthood of Michigan's Youth Advisory Council!

We will be reaching out to set up an interview with you the week of September 15, 2025. If you have any questions, feel free to email Kanyn at kanyn.doan@ppmi.org
Should be Empty:

Thank you SO much for your interest in representing your community in Planned Parenthood of Michigan's Youth Advisory Council! We will be reaching out to set up an interview with you the week of September 15, 2025. If you have any questions, feel free to email Kanyn at kanyn.doan@ppmi.org

Thank you SO much for your interest in representing your community in Planned Parenthood of Michigan's Youth Advisory Council!

We will be reaching out to set up an interview with you the week of September 15, 2025. If you have any questions, feel free to email Kanyn at kanyn.doan@ppmi.org