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
Can we text you about meetings, events, and opportunities?
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
Parents/Guardians, can we text you about updates, questions, or opportunities?
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: