2013-2014 Student Application

Deadline for receipt of application is September 20, 2013

Participation in the Youth Fund Distribution Committee is a serious commitment that requires attendance at all 7 of the meetings held at the West Woods Nature Center in Novelty.

Meetings are held once a month on Monday evenings, 7:00 – 8:30pm, October - May

An excused absence is required if you are ill or must miss a meeting for any other reason. No more than two excused absences are allowed to maintain your status as a YFDC Committee Member.

(PRINT NEATLY OR TYPE)

Name

/

Grade

/ ____ /

Gender

/ M q / F q

Date of Birth

/ / / / Your present age

Address

/ City, State, Zip

Home phone

/ ( ) /

Cell phone

/ ( ) /

Can we text you at this number?

/ Yes q / No q

Email Address

School

School Address /

City, Zip

/
School Counselor/ Advisor Name / Counselor/Advisor Telephone / ( )
Counselor/ Advisor Email
I recommend this student for participation in the Geauga Youth Fund Distribution Committee and understand that he/she will be required to miss one day of school in spring, 2014.
Advisor/Counselor Signature______Date______
Please briefly describe your volunteer experiences at school, church, United Way, other: (you may use a typed sheet)
Why would you like to be a part of the YFDC Committee?

I plan to attend all 7 YFDC meetings and will contact United Way ahead of time to let them know if I must miss a meeting (excused absence). I also understand that if I miss a meeting without an excused absence or miss more than two meetings under any circumstances, I may be removed from the committee.

Student Signature______Date______

Parent Signature______Date______

RELEASE FORM

I hereby give consent to the reproduction and use of my name, likeness, case history, voice, photograph or other representation of myself by United Way Services of Geauga County and/or their nominees and substitutes, and their agents or agencies for publicity and art purposes in any and all print media, online use, advertising and publicity media, including audio recordings, television

and video, without limitations or reservations.

This paper is signed as a release and satisfaction for any claims which may arise out of the use of such photographs, art, print or other publicity material, and any transportation provided by United Way in conjunction with the production of any such publicity material.

Date of signature: ______

______

Name of Individual being photographed (please print) Signature

______

Parent/Guardian (if subject is under 18 years of age) Signature

______

Home Address City State Zip

______

Address (if different than above) City State Zip

______

Daytime Phone # Evening Phone #

United Way Agency Affiliation: Youth Fund Distribution Committee

Description of photo/event: Geauga County

Please return this form with your YFDC application

Parent/Guardian Permission

I understand that all information on this form is voluntarily supplied and may be used and disclosed for volunteer purposes only. I also agree to release and hold harmless the staff, volunteers, and board of directors of United Way Services of Geauga County from any and all liability for disclosing this information to agencies and their agents who request volunteer assistance or for any injury incurred while on a volunteer assignment. I hereby volunteer the services of my child and understand that my child is not a paid employee of any agency or group to which I may not accept assignment, nor is my child an employee of United Way Services of Geauga County.

By signing this application, I (parent/guardian) give consent for my son/daughter to participate in any volunteer activities as provided by United Way Services of Geauga County.

______

Youth Applicant Signature Parent/Guardian Signature

Parent/Guardian Name (Please Print)

Date Date

Deadline for the receipt of the application is

Friday, September 20, 2013

Please return application to Joann Randall, United Way Services of Geauga County

209 Center St, Chardon, OH 44024 or FAX (440) 286-3442

Phone (440) 285-2261 Ext. 225