Student Government Day Application
Name: / Click here to enter text. /Address: / Click here to enter text.
Current Academic Year: / Click here to enter text.
High School Information
Please select your High School:
☐Henry Foss ☐Stadium ☐Wilson ☐IDEA ☐Lincoln ☐Mount Tahoma ☐Oakland ☐SOTA ☐SAMI ☐Willie Stuart Academy
Demographic Information
The following demographic information is voluntary, but would assist us in meeting our goals for this program.
Age: Click here to enter text.
Gender:
☐African American / Black
☐Caucasian / White
☐Native American / Alaskan Native
☐Asian / Pacific Islander
☐Hispanic / Latino
☐Two or more races
Questionnaire
1)How many council members are elected to Tacoma City Council?
☐9 ☐15 ☐4
2)Have you considered pursuing a career in local government?
☐Yes ☐No ☐Maybe
What are your plans after you graduate high school?
☐4 year college ☐2 year college ☐Technical or vocational school ☐Getting a Job
To the best of your knowledge, what is the role and function of city government?
What is the name of the City Council member who represents you?
☐Council member Anders Ibsen (District 1) ☐Council Member Robert Thoms (District 2) ☐Council Member Keith Blocker (District 3) ☐Council Member Joe Lonergan (District 4) ☐Council Member Marty Campbell (District 5) ☐Council Member Woodards (at-large) ☐Mayor Marilyn Strickland (at-large) ☐Deputy Mayor Ryan Mello (at-large)
Please explain why you would like to participate in student government day?
Parental Consent Form and Media Release
Thank you for your interest in participating in the City of Tacoma’s Student Government Day on November 1st, 2016. Participation may include, among other things, spending time in or about City of Tacoma facilities or work sites with City of Tacoma staff, learning about how municipal governments operate and about issues facing City of Tacoma.
PARENTAL CONSENT
I understand that this Waiver of Liability Agreement (Waiver) and Parent/Guardian Consent form must be signed by me, or a parent/guardian if I am under 18 years of age, in order to participate in the Student Government Day event sponsored by the City of Tacoma. As a Parent/Legal Guardian I, hereby grant my permission for the above named minor child to participate in student government day with the City of Tacoma. I acknowledge, agree and understand that said participation may involve risks and inherent dangers that may cause injury and/or death. On behalf of myself and the minor above, I agree to assume the liability and obligations referenced above and to release and hold harmless the City of Tacoma and its agents, representatives, and employees of and from all claims, demands, actions, caused of actions, suits, damages, losses and expenses, of any and all nature whatsoever which might arise out of the activities associated with the City of Tacoma Student Government Day.
(Signature) (Date)
MEDIA RELEASE
I grant the City of Tacoma permission to photograph, videotape, or quote my child participating in the Student Government Day event and to use said photographs, videotapes, and/or quotes regarding participation in the Student Government Day program for educational and public interest purposes.
☐Yes ☐No
Emergency Contact Information
Name of Emergency Contact: Click here to enter text.
Emergency Contact Phone Number:Click here to enter text.
Address of Emergency Contract: Click here to enter text.
Relationship of Emergency Contact to Student:Click here to enter text.
Does the student have any known allergies, physical limitations, or other medical considerations for which we might need to make accommodations:Click here to enter text.
Please mail your completed application toDavid Nash-Mendez at the address below by October 20th.
David Nash-Mendez, Management Fellow
Attn: Student Government Day 2016
City Manager’s Office, Room 1200
747 Market Street, Tacoma, WA 98402
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