Youth Council Membership Application

City of Riviera Beach Youth Council Membership Application

The vision for The City of Riviera Beach Youth Council is to empower caring youth who are dedicated to personal development and servant leadership. If you are interested in applying for membership to the Youth Council, please complete the application. Applicants MUST be a resident of Riviera Beach and be in grades 9 through 12 or ages 14 to 18. If completing a paper application, please type or print clearly in blue or black ink. You may attach additional sheets, if necessary. ALL information must be completed in order to be considered for the Youth Council
Name*

First NameLast Name
Date of Birth

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Parent/Guardian*

First NameLast Name
School*
Shirt Size*
Grade*
Current G.P.A*
Weighted G.P.A*
Upload GPA Verification Form*

Browse Files

Cancelof
Click here for GPA Verification Form
The City of Riviera Beach does not discriminate based on race, ethnicity, sex, creed, national origin or disability. This information need not be provided. It is requested to facilitate The City of Riviera Beach’s goal of assembling a diverse group. Omitting this information will not affect your application.
Race or Ethnic Group*

American IndianAfrican AmericanAsianWhiteMiddle EasternHispanicOther
Sex*

MaleFemale
Please check all that apply

I have transportation to get to the Youth Council meetings/events.I initiated my interested in this programI was asked to apply for this position
If asked to apply for this position, please specify by whom
Why do you want to serve as a member of the Youth Council?*
Headshot

Browse Files

Cancelof
What are the (3) three most important issues to you, your friends and your family concerning your neighborhood?*
Please list any other activities you will be involved in during the school year. Include employment, sports, community, school and religious groups.*
What personal skills and characteristics do you possess that would make you a good representative?*
What are you passionate about?*
Are you willing to attend the meetings, events and activities of the Youth Council for one year and commit to making a difference in our city?*

YesNo
Signature Date
Are you interested in community service points for this project?*

YesNo
Signature Date
Name*

First NameLast Name
Email*
example@example.com
Letters of Reference

Please provide two adult references (non-relative) with a phone number and email. You must also attach a letter of recommendation from each person. Please include one letter from your school Principal, Assistant Principal or Guidance Counselor and one letter from a community member who is familiar with you.
First Name* Last Name* Area Code* Phone Number* Email*
First Name Last Name Area Code Phone Number Email*
References

Browse Files

Cancelof
I have read and understand the commitment required for the City’s Youth Council. I also realize the importance of teamwork and cooperation, and I am willing to make this commitment.

Choose one of the following:

1. Essay: Explain in your own words why you should be selected as a Riviera Beach Youth Council. (Word Limit: 400-650 words)

2. Video: Create a compelling 60-second video explaining why you should be selected for the Riviera Beach Youth Council. Be creative and authentic! Your video can include storytelling, visuals, voice-overs, music, captions or anything that captures your passion and vision. (Must adhere to the code of conduct and mission of the Youth Council)

Possible topics: What inspires you; a challenge you want to tackle in the city
Student Signature* Date*
Signature of Parent/Guardian* Date*
Essay or Video

Browse Files

Cancelof
I hereby certify that the information I have given is true and correct to the best of my knowledge. I understand that provision of false information may disqualify my consideration. I authorize the release of this information for verification purposes and understand it will be used only to process my application. I also understand that by submitting this form, I am applying to participate as a member of the Riviera Beach Youth Council and that said application is only complete upon receipt of the Parental/Guardian consent and liability release form and receipt of G.P.A. certification form/class rank verification form signed by my school counselor. Upon submission of the application, I understand that I will be considered for membership with all other applicants and that I may or may not be selected for membership. If selected, I agree to attend the required meetings and events and understand that I will be removed from membership for failure to do so.
Parent/Legal Guardian Permission: I give my permission for
    First Name*   Last Name*
   to apply for membership to the Riviera Beach Youth Council.
I, the undersigned, do hereby consent to my child’s participation in the Riviera Beach Youth Council. I acknowledge that I have read and understand the Riviera Beach Youth Council By-Laws and will allow my child to attend the required meetings and events relative to this program; and that I understand that my child will be removed from membership for failure to do so. I also acknowledge that upon submission of the application, my child will be considered for membership with all other applicants and that my child may or may not be selected for membership. I further acknowledge that my child’s participation in this program is voluntary and I agree to release The City of Riviera Beach and all of their employees, officials, and any and all individuals and organizations assisting or participating in the program from any and all claims for personal injuries and property damage which my child may suffer while participating as a member of the Riviera Beach Youth Council.
Signature of Parent/Guardian* Date* Area Code* Phone Number*
Emergency Contacts
First Name* Last Name* Relationship to Youth* Phone Number* Email*
First Name* Last Name* Relationship to Youth* Phone Number* Email*
Online:

Applications received after 5:00 PM on September 20, 2025, WILL NOT be considered.

Submit

Or

Return Completed Application

In Person To:

City Councilwoman KaShamba Miller-Anderson's (Legislative) Office Attn: Aqueria Wester (Legislative Aide)

600 W. Blue Heron Boulevard Riviera Beach, FL 33404404

Click here for form
Should be Empty:

City of Riviera Beach Youth Council Membership Application

Letters of Reference

Emergency Contacts