Caswell Youth Council Application

DUE JANUARY 17

Please be sure to submit this application for the Caswell Youth Council by January 17, 2025 for consideration. You may find it helpful to copy and paste your answers from another document to ensure you do not lose your work. For questions or assistance please contact Nicole Gibson at ngibson@caswellcountync.gov or 336-694-4129 ext 8125, or Shannon Moretz at smoretz@compassionhealthcare.org or 336-694-9331 ext 221.

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* 1. Who are you?

Name

School

Date of Birth

Mailing Address

City/Town

State/Province

ZIP/Postal Code

Caswell Fire District (Anderson, Casville, Cherry Grove, Leasburg, Milton, Pelham, Prospect Hill, Providence, Semora, Yanceyville

Email Address

Phone Number

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* 2. Other Identifying & Accessibility Information (Note: this information will be used to evaluate equitable selection of applicants and to ensure appropriate accessibility for all participants. The Caswell Youth Council does not discriminate on the basis of sex, gender, race, disability, or country of origin.)

Race

Gender

We strive to host inclusive, accessible events that enable all individuals, including individuals with disabilities or connectivity challenges, to engage fully. Please let us know if you need any specific accommodations to participate and engage.

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* 3. Tell us why you believe it is important for youth to serve as leaders in our community. (250 - 500 words)

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* 4. Tell us about a community issue that you care deeply about. (250 - 500 words)

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* 5. Tell us what you hope to gain from this experience. (250 - 500 words)

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* 6. References (References may be adult staff and/or leaders from school, faith-based groups, other community agencies, employers or coaches. AT LEAST ONE REFERENCE IS REQUIRED. Please ask references to submit their recommendation at https://www.surveymonkey.com/r/CYCREF by January 17, 2025.)

1st Reference Name *

1st Reference Email *

1st Reference Phone Number

2nd Reference Name

2nd Reference Email

2nd Reference Phone Number