Youth Wellness Council Student Application
Personal Information
Student Name
*
First Name
Middle Name
Last Name
Gender
*
Please Select
Male
Female
Nonbinary
Name of School
*
Grade Level
*
Please Select
6
7
8
9
10
11
12
Student E-mail
*
example@example.com
Mobile Number
*
Format: (000) 000-0000.
Address--you know, in case we want to mail you a birthday card, lol
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Allergies
*
Yes
No
If Yes, please specify
Adult T-Shirt Size:
*
Please Select
XS
S
M
L
XL
XXL
XXXL
Are we able to share photos and videos of you on our social media?
*
Yes
No
Parent/Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Relationship to Student
*
Please Select
Mother
Father
Guardian
Parent/Guardian Phone Number
*
Parent/Guardian Email
*
*
I certify that all answers given are true and complete to the best of my knowledge. By completing this application and signing I understand my commitment to attending Youth Wellness Council Meetings and participating to the best of my abilities.
Student Signature
*
Continue
Continue
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