ETA Community Student Council

Empowered To Achieve

Community Student Council (CSC) Interest Form
Introduction
Welcome to Empower To Achieve's

Community Student COuncil

The Community Student Council (CSC) is a youth-led movement empowering students to use their voice, leadership, and community action to create real change.
Complete this short form to tell us a little about yourself and get connected with your city’s CSC pod!
Student's Information

Please complete all student's personal and contact information below
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
Date
School Name
Grade Level
Location

Please answer the following questions
Which city do you live or attend school in?
Enter Other Specified City
Tier Information

Please answer the following questions
Which level of the CSC are you interested in joining?

Junior CSC (Middle School)CSC (High School)CSC Ambassador (College / Young Adult)
Parent/Guardian Contact (Only for Middle School)

Please answer the following questions
Parent/Guardian Name (Only for Middle School)

First NameLast Name
Parent/Guardian Phone Number (Only for Middle School)

Area CodePhone Number
Parent/Guardian Email Address (Only for Middle School)
example@example.com
About You
Why do you want to join the Community Student Council?
What community issues or causes are most important to you?
Next Steps

Please answer the following questions
Would you like to receive text or email updates about upcoming CSC meetings and events?
How did you hear about us?
10. Other thoughts or comments - (Please use this area to convey any other concerns, comments, or feedback you feel may be valuable to Empowered To Achieve CSC Program.)
Should be Empty:

Empowered To Achieve

Introduction

Student's Information

Location

Tier Information

Parent/Guardian Contact (Only for Middle School)

About You

Next Steps