Please enter your first and last name.
* must provide value
(First, Last)
Please enter your preferred name or what you like to be called.
Please list your personal pronouns, such as she/her, he/him, they/them, she/they, etc.
The personal pronouns listed on this form may be used publicly.
Yes
No
If no, please list the personal pronouns you would like to be used publicly.
Please enter your date of birth.
* must provide value
Today M-D-Y
What is your current age?
* must provide value
13 14 15 16 17 18 19 20 21 22
What is the address where you receive mail?
Street name, City, State, Zip code
What county do you live in?
Please enter your email address. Please use an address that you check regularly so you do not miss any further communication about the Youth Advisory Board.
Do you have reliable internet access?
Yes
No
Do you have reliable access to an internet-enabled device, like a laptop, tablet, or smartphone?
Yes
No
Please enter the name of the school you attend.
Add "homeschooled" if applicable.
What grade are you in?
Or, if you are not in school, please choose an option from the dropdown list that best reflects your education or work status.
5th grade 6th grade 7th grade 8th grade 9th grade 10th grade 11th grade 12th grade College or University Trade school or another type of training Serving in the military Working part-time Working full-time Other
If applying over summer break, which grade will you be in this fall?
What organizations are you a member of? These can be organizations at your school, place of worship, in your community, or others.
If you are a member of service or other types of organizations, do you hold any leadership positions, such as president or secretary? If so, please list them here.
If you are a member of service or other types of organizations, please tell us more about your favorite aspects and activities of the organization.
What does "good health" mean to you?
* must provide value
What are your interests/hobbies?
* must provide value
What are your talents or strengths?
* must provide value
What is your favorite way to solve a problem?
* must provide value
Are you willing to participate in research studies conducted by the WVPRC?The West Virginia Prevention Research Center has been funded since 1995 with the aim of transforming public health policies and practices. Through community-engaged research, evaluation, strategic development, and programmatic support, we aim to facilitate community health and youth resilience initiatives. We partner with communities as well as state and national organizations.
YAB members will be informed and required to consent to any proposed research involving their participation.
* must provide value
Yes
No
I understand that membership on the 2021-2022 Youth Advisory Board requires my participation in at least one virtual meeting per month. I commit to attending these meetings and fulfilling the responsibilities of a Youth Advisory Board Member.
Yes
No
The following section is to be completed by a parent/guardian if the applying young person is under the age of 18.
Please enter a parent/guardian name.
If member is under 18 years old.
As the parent/guardian, please describe your relationship to the young person applying to serve on the Youth Advisory Board.
Mother Father Guardian-family member Guardian-not a family member Other
Please enter your email address. Please use an address that you check regularly so you do not miss any further communication about the Youth Advisory Board.
Please enter a phone number where you can be reached regularly. This information is collected for emergency purposes. We will primarily use email communication for all non-emergency messages.
I give permission to the West Virginia Prevention Research Center and Youth Advisory Board members to photograph/video my young person (with their consent) for promotional and educational purposes. Photos/videos may be used on social media, websites, pamphlets/flyers, presentations, and other forms of communications.
* must provide value
Yes No Other (please describe in the next prompt)
List here the instances where you do not want your (if under 18 years old) youth's image to appear in promotional materials:
Does your young person drive?
Yes
No
I permit my minor young person with a driver's license to transport themself to and from YAB-related activities.
*NOTE: The only in-person activity scheduled for this year's Youth Advisory Board is a potential field trip in the spring.
Yes
No
Minor youth includes anyone under the age of 18.
I permit my minor young person to sign themself in and out of in-person YAB-related activities.
*NOTE: The only in-person activity scheduled for this year's Youth Advisory Board is a potential field trip in the spring.
Yes
No
Minor youth includes anyone under the age of 18.
Will you allow your young person to participate in research studies conducted by the West Virginia Prevention Research Center?The West Virginia Prevention Research Center has been funded since 1995 with the aim of transforming public health policies and practices. Through community-engaged research, evaluation, strategic development, and programmatic support, we aim to facilitate community health and youth resilience initiatives. We partner with communities as well as state and national organizations. YAB members will be informed and required to consent to any proposed research involving their participation.
Yes
No
I understand that membership on the 2021-2022 Youth Advisory Board requires my young person's participation in at least one virtual meeting per month. I commit to supporting my young person in attending these meetings and fulfilling the responsibilities of a Youth Advisory Board Member.
Yes
No
Submit
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