Youth Council Application

Please complete this form if you are a young adult ages 13-18 and interested in developing your resume and career skills, coordinating youth events and advocating for your crime prevention in your community! Someone will respond within 24-48 hours with more information.

Name of Interested Youth Council Member

Interested Youth Council Member Phone Number

Interested Youth Council Member Email Address

Street Address

Street Address Line 2

City

Postal / Zip code

Region/State/Province

Facebook Name

School Name

Year You Graduate

Why do you want to be a part of the Youth Council?

What are you looking to get out of the program?

What are your short-term goals?

What are your long-term goals?

What does the word “Success” mean to you?

Parent/Guardian Name

Parent Email

Parent Phone Number

RELEASE, WAIVER OF LIABILITY AND INDEMNIFICATION

General Consent: By signing below, I hereby agree to release and hold harmless Pathway to the Future Learning Center, Inc. DBA Pathway Resource Center, Inc. and its affiliates, Amber Woods Apartments, employees, officers, volunteers, Board of Directors, and contractors from and against all liability because of my child’s participation in all
approved Pathway Resource Center, Inc. programming and/or events. Moreover, as the parent(s) and/or legal guardian(s) of the above referenced youth, I agree to indemnify and Pathway Resource Center, Inc. and its agents, employees, individual staff and volunteer harmless against any and all claims, liabilities, losses, damages, or expenses of any kind, including reasonable attorney fees, sustained as a result of participation in any and all programs and/or events held by Pathway Resource Center, Inc.

Youth Council: I give my child permission to participate in Pathway Resource Center, Inc. programming sponsored and/or hosted by Pathway Resource Center, Inc. I hereby grant permission of my child to be transported to attend programming held at approved programming sites and venues. Programming includes, but is not exclusive
to, ALL Pathway Resource Center, Inc. partnerships, sponsorships, and collaborations, whether taking place daily, weekly, monthly, annually, or otherwise. I understand every reasonable precaution will be taken to always safeguard my child. Furthermore, I understand adequate and appropriate supervision will always be provided during
programming. I have read the above provisions and I do hereby give my permission for my child to fully participate in all programs sponsored by Pathway Resource Center, Inc. I understand that the youth, my child, participates in Pathway Resource Center, Inc. programs, events, trips, and activities at his/her own risk.

MEDIA RELEASE: I grant to Pathway Resource Center, Inc. the exclusive right to use my child's interview/photograph/video or film likeness in media and promotional materials. I authorize others to use all or any part of my child’s interview/photograph/video in related media such as books, magazines, journals, pamphlets, electronic (internet) and other written and video formats. The undersigned also releases Pathway Resource Center, Inc. and its directors, its members, trustees, founders, officers, employees, partners, and agents, from any and all claims, demands, causes of action and suits, including by not limited to, claims for invasion of privacy, defamation, breach of contract or other breach of duty arising out of or in connection with the use of any interview, photograph, video or other media representations.

Parent/Guardian Signature

Date

Youth Signature

Date

Thank you!