Youth Advisory Council Application

2. Name*

3. Gender

   1. Female
   2. Male

5. Address*

7. City*

8. State*

9. Zip*

11. Home Phone

12. Other Phone

14. E-mail

16. Name of School

18. Year in School
    -- Select One --7th Grade8th GradeFreshmanSophomoreJuniorSenior

20. If not in school, when did you last attend full time.
    If not in school, when did you last attend full time.

21. Age*

23. Race/Ethnicity

    1. American Indian or Alaska Native
    2. Asian
    3. Black or African American, Non Hispanic
    4. Hispanic

    1. Native Hawaiian or other Pacific Islander
    2. White, Non Hispanic
    3. Other

25. If other, please specify

27. Are you currently employed?*

    1. Yes
    2. No

28. Hours worked per week:*

32. Parent/Guardian Name (if 18 years or under)

33. Relationship

35. Address

37. City

38. State

39. Zip

41. Home Phone

42. Work Phone

43. Cell Phone

47. Please describe any current or previous involvement with M-NCPPC / Xtreme Teens/ or a youth organization during out-of-school time.

49. Please list any current or previous extracurricular, volunteer experiences or leadership roles you have had in your school or community.

51. Briefly explain why you would like to participate in the Youth Advisory Council.

53. Write a statement describing your feelings on current opportunities for youth voice or youth involvement on important decisions in Prince George’s County.

55. What other problems or issues are most important to you?

57. If you are selected, you will be expected to reach out to your peers in the youth leadership organization that you represent. Please describe some ways you plan to engage your peers.

59. Are you a member of your school’s student council or student government?*

    1. Yes
    2. No

60. Are you a member of another local youth council?

    1. Yes
    2. No

62. If ‘yes’ to the previous question, what is the name of the group(s) and what is your role?

64. Are you a member of a national youth council?*

    1. Yes
    2. No

66. If ‘yes’ to the previous question, what is the name of the group(s) and what is your responsibility?

68. Approximately how many community service hours did you complete in the previous school year?*
    -- Select One --Less than 5 hours5-25 hours26-50 hours51-75 hoursMore than 75 hours

70. The Youth Advisory Council is a time-consuming commitment, please provide a list of your current activities.*

Leave This Blank:


71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit

* indicates a required field