Returning Student Application 2016-17
Deadline for receipt of application is October 15, 2017
You are aware that participation in the YFDC is a serious commitment that requires attendance at all 7 of the meetings that meet as West Woods Nature Center, in Novelty.
Meetings will be held once a month on Monday evenings, 7:00pm – 8:30pm(schedule to be confirmed)
Plus one day of school in early spring
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 Member.
(PRINT NEATLY or TYPE)
Name: ______Home phone:(_____)______
Address: ______City & Zip______
Cell phone: (_____)______May we text you at this number? Y N
Grade: ______
School: ______
School Counselor/Advisor Name______
School Counselor Phone: (_____)______email:______
I recommend this student for participation in the Youth Fund Distribution Committee and understand that he/she will be required to miss one day of school.Advisor/Counselor Signature______Date______
Page Two – Returning Student Application
Please tell us how you would like this next year on YFDC to help you grow & develop new skills. What do you want to do differently? (You may type on separate sheet)
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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______
Email or mail your application and photo release byOctober 1, 2017 to:
Betsy Covington
United Way Services of GeaugaCounty
209 Center Street
Chardon, OH 44024
(216) 436-2046
Or FAX to (440) 286-3442
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: ______
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Name of Individual being photographed (please print) Signature
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Parent/Guardian (if subject is under 18 years of age) Signature
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Home Address City State Zip
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Address (if different than above) City State Zip
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Daytime Phone # Evening Phone #
United Way Agency Affiliation: Youth Fund Distribution Committee
Description of photo/event: GeaugaCounty
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.
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Youth Applicant SignatureParent/Guardian Signature
Parent/Guardian Name (Please Print)
Date Date
Deadline for the receipt of the application is
September 23, 2016
Please return application to Betsy Covington, ,
United Way Services of GeaugaCounty
209 Center St, Chardon, OH44024 or FAX (440) 286-3442
Phone (216) 436-2046