YAC Membership Application

    APPLICANTS MUST BE AT LEAST 16 YEARS OLD.

    All fields with an asterisk(*) are required.

    APPLICANT INFORMATION

    Full Name*:

    Address*: Apt/Unit#:

    City*: State*: Zip*:

    Phone*: Email*:

    Have you ever worked for Bright Minds?* YesNo

    If yes, how many years?

    EDUCATION

    High School*: Address*:

    GPA: Did you graduate? YesNo If not, grade level?

    College: Address:

    College GPA: Did you graduate? YesNo

    If you graduated, Degree?

    Click one, if applicable: FreshmanSophomoreJuniorSenior

    REFERENCES

    Please list professional references.

    Reference 1

    Full Name*: Relationship*:

    Company*: Phone*:

    Address*:

    Reference 2

    Full Name*: Relationship*:

    Company*: Phone:

    Address*:

    SHORT ANSWERS

    What qualities can you bring to the BMYD Youth Advisory Council?*

    What do you hope to gain from this experience?*

    DISCLAIMER AND SIGNATURE

    I certify that my answers are true and complete to the best of my knowledge. I agree to adhere to attendance policies, implement duties and responsibilities, and commit my membership to a full term (June-July).

    Signature*:

    Date*:

    (By entering your name, you agree to accept the terms of the above document with an electronic signature.)

    Question, comments, concerns? Please do not hesitate to contact:

    Alexus Williamson | Youth Advisory Council Coordinator| alexus@brightmindsyouth.org