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TOWN OF CUTLER BAY
YOUTH COUNCIL COMMITTEE
APPLICATION
STUDENT INFORMATION
Student Name: ____________________________
Home Address: ___________________________
Home Phone: _____________________________
School Name: _____________________________
Parent/ Guardian Name: _____________________
Email Address: ____________________________
City: __________ State: ____ Zip Code: ________
Cell Phone: ________________________________
Grade Level: _____________ Age: ____________
Parent/Guardian Phone: _____________________
I have read and understand the commitment required as a member of the Town of Cutler Bay
Youth Council Committee. I will be a positive representative of youth in the community and serve to
accomplish the goals and duties of the Youth Council Committee.
Student Signature: __________________________ Date: _________________________________
PARENT/GUARDIAN PERMISSION
I hereby give permission for __________________________________ to apply to and participate as
a member of the Town of Cutler Bay Youth Council Committee.
Parent/Guardian Signature: ___________________ Date: __________________________________
STUDENT ASSESSMENT
1. Why do you want to serve as a member of the Town of Cutler Bay Youth Council Committee?
2. Explain how you are involved in your school and/or community. List all extracurricular activities.
3. What skills, talents and abilities do you have that will be beneficial in accomplishing the goals and
duties of the Town of Cutler Bay Youth Council Committee?
YOUTH COUNCIL COMMITTEE APPLICATION
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