Youth Advisory Group Application

Youth Advisory Group Application
Your Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Yes, text me!No, email only please!
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email*
example@example.com
Yes, text me!No, email only please!I prefer a phone call, thank you!
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Education Level*
School Name*
Why are you interested in joining the Youth Advisory Group?*
Please tell us your other community, school, or work experiences.*
What are your interests?*
What are your skills?*
ie. Graphic Design, Social Media
Acknowledgement & Responsibility Statement

By submitting this application, I affirm that the information provided is true and accurate to the best of my knowledge. If selected to serve as a member of the Youth Advisory Group, I understand that I am expected to act as a responsible and respectful representative of my peers and community. I agree to uphold the mission and values of the Nassau County Coalition for Community Health and to conduct myself in a manner that reflects integrity, accountability, and good citizenship.
Applicant Signature*
Parent/Guardian Signature*
Should be Empty: