City of Middletown

Youth in Government Application

Contact:Justin Carbonella
Phone: 860-854-6030 / Fax: 860-854-6028 / Email:

Requirements:

  1. Students in grades 9-12 that reside and/or attend a high school in Middletown.
  2. Attend at least 1 meeting per month.
  3. Agree to serve at leasta one 1-year term.
  4. Have permission from parent/guardian.
  5. Able to attend the Orientation at City Hall on Monday, November 2, 2015 (@ 6p.m.) and Swearing in with the Mayor (@ 7p.m.).

DEADLINE TO APPLY: Friday, October16th, 2015by 4p.m.

Please bringthe completed application tothe guidance office at Middletown High School. Or, youmayalso fax, email, or deliver /mail the application to:

Middletown Youth Services Bureau, 372 Hunting Hill Avenue, Middletown, CT 06457

Or, email , orFax: 860-854-6028.

Name: ______Grade: _____ Date of Birth: ______

School: ______Phone: ______

Address: ______Email:______

  1. Please attach a 1-page essay which answers at least one of the following questions:

a)What skills or characteristics do you possess that make you a good representative for youth?

b)What are three issues that you feel need to be addressed in Middletown?

c)Select one of those issues and briefly explain how you, city agencies and residents can address this concern effectively.

d)List any activities that you are currently involved in (leadership activities; sports; community activities; school activities)

By signing below you agree to make these meetings a priority and acknowledge that two unexcused absences may result in removal from this program.

Your Signature______Date:______

The following is a list of boards; committees; and commissions. Please identify which boards you would be interested injoining by using numbers like so, 1-very interested, 2-interested, etc.Selections do not guarantee appointment to a particular board.

___ Board of Health___Long Hill Estate Authority

___Cable Advisory Board___Middletown Commission on the Arts

___Citizens Advisory Committee___Middletown School Readiness Program

___Design Review and Preservation___Parks and Recreation Committee

___Redevelopment Agency___Human Relations Commission

___Youth Services Advisory Board___Committee Concerning People with Disabilities

We ask that you also have parental/guardian permission to be involved with this program:

Parent/Guardian:______Date:______