Youth Advisory Council (YAC) Application 1Your Information2Parent/Guardian Certification3Medical Information4Student Certification YOUR INFORMATIONYour Legal Name(Required) First Last I prefer to be called …Your Pronounsselect as many as you wish He/him She/her They/them Other Other pronoun(s)(Required)Your Age(Required)Your Date of Birth(Required) Month Day Year What school do you attend?(Required)What grade are you in for the 2023/2024 school year?(Required) 8th 9th 10th 11th 12th What is your T-shirt size?(Required) Small Medium Large XL 2XL 3XL Your Home Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Cell Phone Numberused to send meeting remindersYour Email Address(Required)not your school email; used to send meeting reminders How do you prefer to be contacted about YAC meetings, reminders, etc.?(Required) Text message Email How would you describe your gender identity?(Required)this information will remain confidential Man Woman Nonbinary Prefer to self-identify Prefer to not respond Please describe your gender identity(Required)Which of the following racial/ethnic categories do you identify with?(Required)this information will remain confidential American Indian or Alaskan Native Asian Black or African American Hispanic or Latino Native Hawaiian or Pacific Islander White Prefer to not respond Are you able to provide your own transportation to and from YAC activities?(Required) Yes No Other Other means of transportation (please explain)(Required)Why would you like to become a member of Youth Advisory Council?(Required)How did you hear about Youth Advisory Council?(Required)Would you like to receive a monthly postcard in the mail listing the month’s YAC activities?(Required) Yes No Parent/Guardian CertificationIf you are under 18 years of age, the content in this application must be certified by your parent or guardian. An email will be sent to the parent/guardian’s email address that you will provide in the this section of the application. They must complete the certification process. If you are over 18 years of age, you can self-certify your application.Age Certification I’m under 18 and do need parental consent. I’m 18 or over and do not need parental consent. Your Parent/Guardian's Email Address(Required)used for certifying this application MEDICAL INFORMATIONPrimary Parent/Guardian Name(Required) First Last Primary Parent/Guardian Cell Phone(Required)Primary Parent/Guardian Work PhoneEmergency Contact InformationEmergency Contact Name(Required) First Last Relationship to YAC member(Required)Emergency Contact Cell Phone(Required)Emergency Contact Home PhoneEmergency Contact Work PhoneYour Health History(Required)check all that apply Asthma Epilepsy Diabetes Other None Other Health History(Required)please describeYour Allergies(Required)check all that apply Drug allergies Food allergies Other allergies None Drug Allergies(Required)please listFood Allergies(Required)please listOther Allergies(Required)please listYour Medicationstype and dosage STUDENT CERTIFICATIONMedical Treatment Authorization(Required)I authorize representatives of Roscommon County Community Foundation to transport, request, and authorize treatment for me in the event of an accident, injury, or illness. I agree that I will not hold this person liable while they are acting according to these directions. I agreeYouth Advisory Council Waiver and Release of Liability(Required)I, the Youth Advisory Council Member, waives, releases and agrees to hold harmless the Roscommon County Community Foundation and the agency or organization, and their respective agents, officers, board members, representatives, employees and volunteers (the “Releasees”) from any liability to the undersigned and the personal representatives, heirs, assigns, and family of the undersigned, for all loss or damages on account of injury to the person or property of myself (the YAC member) relating to attendance at the event or transportation to or from the event, whether caused by the negligence, gross negligence or recklessness of the Releasee or otherwise. I have read the Waiver and Release of Liability and voluntarily signs. I agreeYouth Advisory Council Media Release Form(Required)Your image may be used in the following forms of media: News Release Photographs Video Audio Website Social Media The Roscommon County Community Foundation may use your image for a period of up to 5 years from the date of this release for the purpose of promoting youth philanthropy. I give my permission to the Roscommon County Community Foundation to use my name and/or photograph, videotape, or any likeness for publicity and the use of statements made by or attributed to me relating to the Roscommon County Community Foundation for this or similar promotions and grant to the Roscommon County Community Foundation any and all rights to said use without further compensation. It is my understanding that my signature below releases the Roscommon County Community Foundation from any financial or legal responsibility for the use of this media relations/promotional material(s). I agree I opt out Non-Discrimination Policy(Required)The Roscommon County Community Foundation follows an equal opportunity employment policy and employs personnel without regard to race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, physical or mental ability, pregnancy, veteran status, military obligations, and marital status. This policy applies to hiring, internal promotions, training, opportunities for advancement, and terminations. The Foundation’s grant making policies reflect the belief that organizational performance is greatly enhanced when people with different backgrounds and perspectives are engaged in an organization’s activities and decision-making process. Thus, the foundation actively seeks to promote access, equity, and inclusiveness, and no person shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity funded in whole or in part with funds made available by the community foundation, and any other program or activity funded in whole or in part with funds appropriated for grants, cooperative agreements, and other assistance administered by the community foundation based on race, creed, ethnicity, gender, age, sexual orientation, socioeconomic status, and other factors that deny the essential humanity of all people. This principle is a lens through which all the work of the Foundation is viewed. I have read and understand the Non-Discrimination Policy.By applying, I also pledge to accept and follow-through on the responsibilities that come with this position:(Required) To attend meetings held monthly. If I have to miss a meeting, it will be an exception to my regular attendance and I will give my Advisor at least 2 days’ notice. To review my packet of grant requests and other information that is sent to me before the grant screening meeting begins, so that I may be prepared and contribute to the meeting. To avoid conflicts of interest and appropriately handle actual or apparent conflicts of interest in my relationships. To keep meeting materials and discussions confidential. To be a responsible steward of the money allocated for youth in our community. I will form my opinions objectively and without bias so that decisions made reflect the community’s best interest. I understand that action which reflects negatively on the YAC and/or the RCCF may be considered grounds for review of my continued membership. I agreeStudent Certification(Required)By clicking on the “I certify” checkbox below, I agree to the above terms and acknowledge that the information provided in this application is accurate. I certifiyThis field is hidden when viewing the formPARENT/GUARDIAN CERTIFICATIONThis field is hidden when viewing the formMedical Treatment Authorization(Required)I authorize representatives of Roscommon County Community Foundation to transport, request, and authorize treatment for my child in the event of an accident, injury, or illness. I agree that I will not hold this person liable while they are acting according to these directions. I agreeThis field is hidden when viewing the formYouth Advisory Council Waiver and Release of Liability(Required)I (the parent/guardian) waive, release and agree to hold harmless the Roscommon County Community Foundation and the agency or organization, and their respective agents, officers, board members, representatives, employees and volunteers (the “Releasees”) from any liability to the undersigned and the personal representatives, heirs, assigns, and family of the undersigned, for all loss or damages on account of injury to the person or property of the my child (the YAC member) relating to attendance at the event or transportation to or from the event, whether caused by the negligence, gross negligence or recklessness of the Releasee or otherwise. I have read the Waiver and Release of Liability and voluntarily agree. I give my permission for my child to attend all YAC events and I further agree to all the terms of the Waiver and Release of Liability stated herein.This field is hidden when viewing the formYouth Advisory Council Media Release Form(Required)Your child’s image may be used in the following forms of media: News Release Photographs Video Audio Website Social Media The Roscommon County Community Foundation may use your child’s image for a period of up to 5 years from the date of this release for the purpose of promoting youth philanthropy. I give my permission to the Roscommon County Community Foundation to use my child’s name and/or photograph, videotape, or any likeness for publicity and the use of statements made by or attributed to me relating to the Roscommon County Community Foundation for this or similar promotions and grant to the Roscommon County Community Foundation any and all rights to said use without further compensation. It is my understanding that my signature below releases the Roscommon County Community Foundation from any financial or legal responsibility for the use of this media relations/promotional material(s). I agree I opt out This field is hidden when viewing the formCertification(Required)By clicking on the “I certify” checkbox below, I agree to the above terms and acknowledge that the information provided in this application is accurate. I certifiyThis field is hidden when viewing the formParent/Guardian's Name(Required) First Last This field is hidden when viewing the formToday's Date(Required) Month Day Year This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.EmailThis field is for validation purposes and should be left unchanged.
