City of Claremont Teen Committee Application

City of Claremont
Application for Appointment to Teen Committee
Date of Application:

MonthDayYear
Date
(Due by May 22, 2026)
PERSONAL INFORMATION
Name:

First NameMiddle InitialLast Name
Residence Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-Mail Address:
example@example.com
Cell Phone Number:
Format: (000) 000-0000.
Parent/Guardian Name:
Parent/Guardian Cell Phone Number:
Format: (000) 000-0000.
School:
Grade 2026/2027:
How long have you been a resident of Claremont?
List three (3) personal references that can provide information on your relevant interests, experience, and ability to work productively as a part of a team. Include name, address and current phone number for all references.
The City would like to ensure that a broad cross-section of the community is represented on the Teen Committee.
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BIOGRAPHY/COMMUNITY INVOLVEMENT/INTERESTS
In order to create a committee with a membership that incorporates a broad range of qualifications and community interests as well as fulfills the goals and expectations of this process, please provide the following information about yourself on a separate paper and attach to your application. Your responses do not need to be long, but should be of sufficient length to provide the information requested. Typed responses are preferred (for ease of reading).
1) Why do you want to serve on the Teen Committee?
2) Outline any significant life experiences that you would bring to the committee?
3) List any community groups in which you have been involved. Describe your role in these groups and how this involvement would benefit the Teen Committee.
4) Outline your personal and academic interests and how you believe they are beneficial and relate to the mission of Teen Committee.
5) Please outline your time availability and how you would balance this commitment with any existing time commitments for family, work, education, and/or other activities.
6) Describe any other qualities and/or experience you possess that you believe would be beneficial to the Teen Committee.
Pursuant to the California Public Records Act, portions of this completed application are subject to public disclosure. Additionally, persons holding a position on this Board, Committee, or Commission may be required to file a Conflict of Interest Statement in accordance with the Political Reform Act and the City of Claremont Conflict of Interest Code, which Statement is also subject to disclosure.
The California Penal Code states a person convicted of a felony is prohibited from holding public office, even if the felony has been expunged.
I declare under penalty of perjury that the foregoing is true and correct. Executed this day.

MonthDayYear
Date
(Applicant Signature)
(Parent/Guardian Signature)
Claremont Recreation and Human Services Department,

1700 Danbury Rd, Claremont CA 91711, 909-399-5490 (rev 06/21)

CITY OF CLAREMONT
WAIVER, RELEASE, HOLD HARMLESS, AND AGREEMENT NOT TO SUE
Activity:
I understand and acknowledge that, although the City of Claremont takes measures to ensure participants' safety, there are inherent risks associated with the above-referenced activity/event, such as property damage, injury, illness, and death. To the extent permitted by law, I on behalf of myself, my heirs, and my personal representatives, and on behalf of any minor children listed above - hereby agree to release, indemnify, defend and hold harmless the City of Claremont and its officials, officers, employees, contractors, volunteers, and agents from and against any and all liabilities, claims, penalties, losses, or expenses (including attorneys' fees), of any kind or nature whatsoever, whether related to bodily injury, property damage, or any other form of injury or loss, caused by any negligent act or omission of the City of Claremont or its officials, officers, employees, contractors, volunteers, and agents, arising out of or in any way related to the activity/event.
If I observe any unusual or significant hazard during the activity/event, I will take immediate precautions to ensure my safety (such as leaving the activity or event, if necessary) and immediately bring the hazard to the attention of the City staff or the City's Police Department. I hereby authorize the City of Claremont to call for emergency assistance (including an ambulance) in case of accident or acute illness, and to arrange for necessary medical or surgical care for me/any child listed above in the event that the emergency contact person(s) designated are unavailable. I understand that a conscientious effort will be made to notify me or the emergency contact person designated at the time of enrollment before such action is taken. I am participating/allowing any children listed above to participate at my own risk.
I understand and agree that, as a participant in this activity/event, I and any children listed above may be photographed, and I agree that the City may use such photographs for City purposes (such as to publicize City activities/events) without compensation and without further permission.
I certify that I have read and understand this waiver and release. I certify that I have capacity to sign this contract for any minor children listed below (i.e., I am their parent, legal guardian, or I have authorization from their parent or legal guardian to contract on their behalf). By signing below, I am accepting these risks and responsibilities for myself and for any children listed below.
Participant Name (Print)
Date of Birth

MonthDayYear
Date
Signature of Participant (if adult) or Parent/Legal Guardian (if minor)
Date

MonthDayYear
Date
Parent or Legal Guardian Name (if participant is a minor)
Should be Empty:

City of Claremont

Application for Appointment to Teen Committee

PERSONAL INFORMATION

BIOGRAPHY/COMMUNITY INVOLVEMENT/INTERESTS

CITY OF CLAREMONT

WAIVER, RELEASE, HOLD HARMLESS, AND AGREEMENT NOT TO SUE