Youth Advisory Committee
Membership Form and Parent Release

What is expected of a YAC member?

Develop an understanding of philanthropy and service.
Attend a minimum of 7 meetings or community service activites each school year (to qualify for a $100/year scholarship from the Community Foundation).
Help organize and participate in community service projects.
Review grant applications and make recommendations to the Foundation's Board of Directors on grant recipients.

Student Information

Student Name

Date of Birth

Primary Address

City

State

Zip Code

Cell Phone

Home Phone

How did you hear about YAC?

How would you describe your personality/character?

What will you bring to YAC?

What interests you about the Youth Advisory Committee (YAC)?

If you had $5,000 to make your community a better place for teens, how would you use it?

What days and times would work best for you to attend YAC meetings?

Can you commit to attending at least seven YAC meetings and/or YAC ommunity service activities this school year?

What school do you currently attend?

What extracurriculars do you participate in?

What year will you graduate?

Please list your allergies, medical conditions, or other needs/precautions.

What medications do you take that YAC advisors or medical personnel should be aware of?

Parent/Guardian Information (if student is under 18)

Parent/ Guardian Name

Cell Phone

Home Phone

By completing this form, I declare that I am the parent/legal guardian of the above-named minor child.

Emergency Contacts

Contact Name #1

Relationship to child

Phone

Contact Name #2

Relationship to child

Phone

Waiver and Release of Liability

YAC Member's Name

Parent/legal guardian, please read and initial each item below and sign at the bottom.

WAIVER AND RELEASE OF LIABILITY: I waive, release and agree to hold harmless M&M Area Community Foundation (MMACF) and its respective agents, officers, board members, representatives, employees, YAC advisors, and volunteers (the "Releases") from any liability, claims, demands, damages, costs, expenses and compensation to the undersigned, the YAC member and their personal representatives, heirs, insurers, assigns, and family member, for all loss or damages on account of injury to the person or property of the above-named YAC member relating to participation in the YAC or transportation to or from YAC activities. The undersigned have read the Waiver and Release and voluntarily sign.

AUTHORIZATION FOR MEDICAL TREATMENT: I realize that situations may arise that require medical services and treatment be provided to the YAC member. I also understand that circumstances may not always permit referral to the information contained in this permission and release form prior to the rendering of treatment and medical services. Therefore, in my absence or unavailability I hereby give permission to authorized medical of MMACF personnel to treat and provide medical services to the YAC member identified above which said persons believes to be medically necessary. I hereby waive, release and agree to hold harmless the Releases from liability for these medical services and treatment without regard to any notice which may be obtained in this permission form. Medical services and treatment include but are not limited to transfer of my child by ambulance or other means to a hospital or clinic and referral to a physician as deemed appropriate by the above authorized personnel. Further, I assume responsibility for all financial obligations for these medical services and treatment.

MEDIA RELEASE: I give my permission to the MMACF to use the YAC member's name, photograph, video, the use of statements made by or attributed to the YAC member, or any likeness for publicity or similar promotion, and grant the MMACF any and all rights to said use without further compensation. I understand that my signature below releases the MMACF from any financial or legal responsibility for the use of media/promotional materials.

CONSENT FOR TRANSPORTATION: (Please note: YAC advisors have passed a criminal background check and undergo periodic driving record checks.) I give my permission to the MMACF Staff and YAC Advisor(s) to provide transportation for the YAC member in connection with YAC activities.

PERMISSION TO PARTICIPATE: If the YAC participant is under the age of 18, I hereby give my permission for him/her to participate in the Youth Advisory Committee of the M&M Area Community Foundation as described above and I further agree to all the terms of the Waiver and Release of Liability stated herein.

Signature

Parent/legal guardian

Date

Contact Information