First Name * Last Name * Address * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * Phone * E-mail * Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027 School * Grade/Year in School (i.e. 11th grade or 3rd year college) * Complete the following statement, “Upon hearing about the Youth Advisory Committee and what is expected of me, I hope to gain the following from this experience: I currently participate in the following academic, extracurricular, community, or volunteer activities. Describe your role in the activity. I feel I am an excellent candidate for the Student Advisory Council because of the following reasons: I realize that my character as a person is important. The following people would describe me as: Friend: Teacher/Coach: Family Member: To maintain active membership on the Culture Shock Miami Advisory Committee and to be eligible for trips and service hours, individuals selected must attend monthly meetings regularly and participate in other scheduled activities unless an excused absence is obtained. I have read and understand this stipulation. * - Select -YesNo If under 18 years old, please complete the following: Parent/Guardian Name Parent/Guardian Phone Parent/Guardian Email
