CITY OF PEORIA, AZ YOUTH ADVISORY BOARD APPLICATION SCHOOL GRADE LAST NAME FIRST NAME ADDRESS ZIP DISTRICT / HOME PHONE and/or CELL PHONE NUMBER PLACE OF EMPLOYMENT/PHONE # (if any) AM/PM BEST TIME TO CALL (Circle One) E-MAIL ADDRESS ______________________________________________ _______________________________ ANTICIPATED DATE OF HIGH SCHOOL GRADUATION FAX NUMBER PART I I. If appointed, how much time are you able to devote to the Youth Advisory Board? (Give number of hours) Hours per week ____ Hours per month ____ This Board typically requires approximately 8 to 10 hours a month. II. Best meeting days/times: ? all that apply (Please indicate times available) Monday ? Tuesday ? Wednesday ?? Thursday ?? Friday ? Days ? Evenings ? Either ? Meetings will be held from 6:30 to 8:00 p.m. on the second Tuesday of every month. III. How long have you lived in Peoria? Years Months (Please Continue) 1. Please tell us why you wish to be appointed to the Youth Advisory Board? 2. A.) What volunteer activities have you been involved in or are you currently involved in? B.) What extra curricular activities, hobbies, and other interests do you enjoy? 3. Give any qualifications, education or experience you have which may pertain to the Youth Advisory Board? (Please Continue) 4. Have you served in a leadership capacity and if so, what were your duties and how long was the commitment? 5. Have you ever served on a Committee? If yes, please provide details. 6. Have you or any family members, currently or in the past, ever served on a Board/Commission for the City of Peoria? If so, please name the Board/Commission and/or family member and the dates served. 7. Do you have any family members employed by the City of Peoria or serving on the City Council? If yes, please name the employee/Councilmember. Additional Comments: Signature Date (Please Continue) Permission Form: To be filled out by applicant’s parent(s) or legal guardian. I grant permission for my child, named above, to participate in the YOUTH ADVISORY BOARD AND RELATED ACTIVITIES. I/we hereby release and forever discharge the Mayor and Council of the City of Peoria, Maricopa County, Arizona, a municipal corporation, and any and all other person, firms, or corporations who are or might be liable, from any and all claims of any kind or character which I/we have or may have against it or them, including transportation to or from any portion of this program, and in that regard, I/we covenant to indemnify and hold harmless the foregoing from any loss or damages, including reasonable attorneys fees which may be by them incurred I the event of any such claims are asserted against them or any of them. I/we additionally permit the free use of my child’s name and picture in broadcasts, newspapers, etc. Please Print Name: ________________________________________________ Sign: ________________________________________________ Please complete this application and return to: City of Peoria Office of the City Clerk 8401 West Monroe Street Peoria, AZ 85345 Application Form for Boards and Commissions FOR OFFICE USE ONLY Board/Commission New Appointment Underfilling Term Name of Member Replaced Date Appointed Term Expiration Resolution # Date Re-appointed Term Expiration Resolution # Date of Resignation (If applicable) Board/Commission New Appointment Underfilling Term Name of Member Replaced Date Appointed Term Expiration Resolution # Date Re-appointed Term Expiration Resolution # Date of Resignation (If applicable) FROM:___________________ _________________________ _________________________