YAB Application - REPSC.org

Name

First Last

Date of Birth

Current Grade in School

School Name

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Best time to call you?

Email

Parent/Guardian Information

Parent/Guardian Name

First Last

Parent/Guardian Phone

Parent/Guardian Email

Emergency Contact Name (if different from Parent/Guardian):

First Last

Emergency Contact Phone

1. Why do you want to be a part of the Youth Action and Advisory Board guiding others on teen dating violence prevention?*

2. Why do you think you would be an asset to the Youth Action and Advisory Board?*

3. What actions have you taken in your local community to prevent or spread awareness about teen dating violence?*

Consent

I agree to the privacy policy.