YAB Member Interest Form

YK4A Youth Action Board (YAB)

Member Interest Form
Your Name*

First NameLast Name
Pronouns
Race
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number
What county do you currently live in?
Do you have lived experience of housing instability or homelessness (couch surfing, doubling up in homes, literal homelessness on the streets, or a place not livable such as a car or abandoned building/park/any other place not meant for sleeping, foster care, or juvenile corrections?)
What county/state did you experience housing instability?
Do you identify as any of the following populations?

Black, Indigenous, People of Color (BIPOC) or any other racial minorityPregnant or ParentingFleeing violence (Intimate Partner violence, trafficking, or domestic violence within the home)Foster Care (current or in the past)LGBTQIA2S+Unsheltered (current or in the past)Person with a disability (seen or unseen)Veteran (current or in the past)Minor (under the age of 18)Juvenile Corrections (current or past)NeurodivergentOther
Do you need accommodation services in order to participate in the YAB?*

YesNo
Please list any accommodations needed, including laptops or transportation. Please type N/A if accommodations do not apply.*
How did you hear about the YAB?*
Case Worker, friend, website, Facebook, etc.
Emergency Contact*
Is there any other information you would like to share including social media profiles or other barriers related to your situation (work or school schedule)?
I prefer to receive payment for participation in YAB activities by:

paper checkdirect deposit
Photographic & Borrowed Technology-Member Release

I hereby acknowledge that the information given above is accurate and I give permission to KSHC and BOS COC to use any photographs taken by staff, and stories or quotes, for use of social media/marketing/website purposes. If I am utilizing KSHC technology, such as a laptop, I agree to care for said tech and return after my time in the YAB is completed or I decide to cease being a YAB member. I also understand tech is monitored by MCubed technologies for virus protection.
Signature

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YK4A Youth Action Board (YAB)