Youth Committee Application 2022-2023

Youth Committee Application 2022-2023
Are you interested in organizing and planning health-related events and creating health campaigns to share in your community? Join the Shiawassee County Health Department’s Youth Committee so your voice can be heard!

The committee will focus on the following topics: substance use prevention, reproductive health, nutrition, and mental health.

This group will create, plan, and host events and initiatives related to teen health. It will meet once a month (3rd Thursday of the month) at the Shiawassee County Health Department or virtually for approximately one hour.

Once you have completed the application, you will be notified of meeting dates, times, and locations.
Student Information
Student Name:

First NameLast Name
Student Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Phone Number:
Please enter a valid phone number.
Student Email Address:
Please use personal email vs. school email address
Student Grade Level:
School Name:
Student Personal Insight
As a member of the SCHD Youth Committee your opinions and ideas about prevention are extremely important to us. Please take a few moments to answer the following questions.
What are three health topics that you are interested in educating others about?
Think about one of the following topics listed above that youth are facing regarding wellness, health, safety, rights and responsibilities. Discuss the topic and describe why it is important to you, how would you go about educating your community, and list 3 minimum goals and what actions you would take to reach them.
Letter of Recommendation
The Shiawassee County Health Department will email the individual writing the Letter of Recommendation and ask them to complete the letter on your behalf. Please advise the person that you have named them as a person to complete a Letter of Recommendation and that an email will be coming from the Shiawassee County Health Department.
Name of neighbor/teacher/coach that would recommend you for this group:

First NameLast Name
Email of neighbor/teacher/coach that would recommend you for this group:
example@example.com

Parent Information
The Shiawassee County Health Department (SCHD) has started a Youth Committee in hopes of creating a healthier community for today’s youth. The group will work on the following topics: substance use prevention, reproductive health, nutrition, and mental health. This group will plan and host health-related events and activities in Shiawassee County to promote healthy behaviors among their peers. This group will meet once a month either in-person or through virtual meetings for approximately one hour. Sub-committees may meet more often depending on projects and events
Parent Name:

First NameLast Name
Parent Relationship:
Parent Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Phone Number
Please enter a valid phone number.
Photo Release
SCHD/Youth Committee may photograph members during Youth Committee meetings or other activities. These photographs may be used for social media and/or publication to promote the Youth Committee.

YES, it is okay to photograph my child during Youth Committee activities. I understand that these photos may be used for the creation of social media or other publications to promote the Youth CommitteeNO, I do not want my child photographed.
Parent/Guardian Permission
I First Name Last Name permit my child First Name Last Name to participate in the SCHD Youth Committee and attend committee meetings during the 2022-2023 school year. I understand that my child must transport themselves or find alternate transportation to the meetings and/or activities.
Parent/Guardian Signature:

Clear
Should be Empty:

Youth Committee Application 2022-2023

Student Information

Student Personal Insight

Letter of Recommendation

Parent Information

Photo Release

Parent/Guardian Permission