Youth Advisory Council Application

First name of applicant:

Last name of applicant:

Pronouns (for example: she/her):

Street address:

City, State, Zip:

Phone number:

Email address

Birthdate:

Grade in school:

Have you talked to your parent or guardian about joining the Youth Advisory Council?

Yes

Are you able to attend meetings the second Saturday of every month between September and May?

Yes

Are you willing to share your thoughts and ideas about Children’s Minnesota with other group members and facilitators?

Yes

Are you between the ages of 10-18?

Yes

Parent/guardian first name:

Parent/guardian last name:

Parent/guardian email address:

Parent/guardian phone number:

Why do you want to be part of the Youth Advisory Council?

What is your experience with Children’s Minnesota?

Please provide the name of an adult who could provide a recommendation for you to join the Youth Advisory Council:

Adult recommendation phone number:

Adult recommendation email address:

Patients and families