2017-2018 Student Application
Deadline for receipt of application is October 1, 2017
Participation in the Youth Fund Distribution Committee is a serious commitment that requires attendance at all 7 of the meetings held at the West WoodsNature Center in Novelty. Meetings are held once a month on Monday evenings, 7:00 – 8:30pm, October – April schedule to be confirmed.
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 / FDate of Birth
/ / / / Your present ageAddress
/ City, State, ZipHome phone
/ ( )Cell phone
/ ( ) /Can we text you at this number?
/ Yes / No 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 February, 2017.
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: 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.
______
Youth Applicant SignatureParent/Guardian Signature
Parent/Guardian Name (Please Print)
Date Date
Deadline for the receipt of the application is
October 1, 2017
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