APPLICATION FORM:

Due November 30, 2012

Youth @ City Council a civic engagement program

5299 Auburn Blvd. Sacramento, CA 95841 (916) 576-3300 Fax (916) 576-3306 www.peoplereachingout.org CONTACT INFORMATION Student Name: Email Address: Phone Number: ( Home Address: Parent Name: ) Age: High School: District Number: 1 City & Zip Code: Emergency Phone Number: ( ) 2 3 4 5 6 7 8 n/a Grade: 9 10 11 12

PROGRAM OVERVIEW AND STATEMENT OF UNDERSTANDING Youth @ City Council is a 12-month program that meets every other Thursday from 5:00pm to 6:30pm at City Hall. During these class sessions, students will hear from guest speakers, learn about public policy and civic engagement, and participate in conducting research and solution making. In addition, students are required to attend one City Council meeting per month, which occurs every Tuesday from 5:00pm to 8:00pm. Students will have to make their own transportation arrangements to and from City Hall. The program start date will be announced after interviews are conducted. I understand that: Youth @ City Council is a premier and selective civic education program; I am expected to fulfill the time commitment outlined above and provide my own transportation; and I am expected to be respectful to others and prepared to learn about ways to improve my community and city. Date:______________________

Signature: ______________________________________

SHORT ESSAYS Describe an issue in your neighborhood or community that you are passionate about fixing or changing.

Describe your ideas to address that issue.

QUESTIONNAIRE (Demographic information collected per grant reporting requirements, information is kept confidential.) Parent Ethnicity (Mark all that apply): American Indian or Alaska Native Asian Indian Black/African American Eastern European Chinese Filipino Latino(a)/Hispanic Native Hawaiian Japanese Pacific Islander Vietnamese White Multi-Racial Other Asian: (Hmong, Laotian,Thai) Other:

Languages Spoken at Home (Mark all that apply): Arabic Russian Other: Chinese Spanish English Tagalong Hmong Vietnamese Mien Japanese Is anyone is your household receiving? (mark all that apply) RCA SSI CalWORKs Food Stamps Signature of Youth Applicant: _________________________________ PARENTAL/GUARDIAN CONSENT I hereby give my permission for my child to take part in Youth @ City Council, a program of People Reaching Out. I am aware that my child will attend City Council meetings once a month on Tuesdays from 5:00-8:00pm and classes on municipal government, public policy, and civic engagement twice a month on Thursdays from 5:00-6:30pm. It is the childs and parents responsibility to sign up to attend the city council meetings. I am aware that People Reaching Out may have my child share his/her experiences in the program, under the supervision of a People Reaching Out, Inc. staff member, via public media broadcasts such as, but not limited to, television, radio and newspaper. My consent is hereby given to People Reaching Out to use my childs video/voice/photo taken in conjunction with the program in a manner People Reaching Out finds appropriate. I have read, understood, and agree to the parent consent previously stated, and permit my child to participate in all the approved circumstances. I certify that my childs participation in the program is voluntary. Of myself and those who would claim under me, I, release People Reaching Out, Inc. and agency staff from any negligence and liability for loss, injury, or damage to me, my child, or property which may result from my childs participation in program activities or in transit to and from any of the activity location sites. I agree to indemnify, defend, and hold harmless People Reaching Out and program organizers and sponsors, including but not limited to officers, directors, employees, mentors, and successors from any and all claims, lawsuits, and other proceedings, damage, costs, and expenses made by any third parties arising out of any act, omissions, or conduct of my child while s/he is participating as a member of the mentoring program. Parent or Guardian Signature: ___________________________________________ Date: _____________________ NEXT STEPS After reviewing all applications, we will contact you for a possible interview. Please return completed applications to Ijeoma Ononuju by one of the following ways: Email:
ijeomao@peoplereachingout.org

GA

Unemployment Date: ________________

Fax: (916) 576-3306

Mail: 5299 Auburn Blvd. Sacramento, CA 95841