KYC Form Folder

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Kansas Advisory Group
Youth Committee
Membership Application and Participation Agreement

First Name Applicant's First Name

Middle Initial Applicant's Middle Initial

Last Name Applicant's Last Name

Age Applicant's Age

Date of Birth Applicant's Date of Birth

Year / Month / Day

Address Line 1 Applicant's Street Address

Address Line 2 Applicant's Apartment, Suite or Room Number

City Applicant's City

State Applicant's State

Zip Code Applicant's Zip Code

E-Mail Address Applicant's Email Address

Home Phone Number Applicant's Home Phone Number

Cell Phone Number Applicant's Cell Phone Number

Work Phone Number Applicant's Work Phone Number

Are you under age 18?

Yes
No

If you are under age 18, Parent/Guardian information must be provided.

Parent/Guardian First Name Parent/Guardian First Name

Parent/Guardian Last Name Parent/Guardian Last Name

Parent/Guardian Suffix

Address Line 1 Parent/Guardian Address

Address Line 2 Parent/Guardian Address 2

City Parent/Guardian City

State Parent/Guardian State

Zip Code Parent/Guardian Zip Code

E-Mail Address Parent/Guardian E-Mail Address

Home Phone Number Parent/Guardian Home Phone Number

Cell Phone Number Parent/Guardian Cell Phone Number

Work Phone Number Parent/Guardian Work Phone Number

Are you currently going to school?

Yes
No

If you are attending school:

Name of School Applicant's School Name

Location of School Applicant's School Location

Grade Level Applicant's Grade Level

Which of these best describes you?

If Other, please explain:

Name Three (3) of Your Strengths

What do you feel youth need to be successful?

What issues about youth do you feel strongly about? (such as juvenile justice system, foster care, probation, high minority incarceration rates, school violence, etc.) Please describe:

If you could change one thing for youth in the juvenile justice system, what would it be?

Please write a short essay explaining why you wish to serve on the Youth Committee: Applicant's Essay

How did you hear about the KYC?

REFERENCE (Someone over the age of 18 years)

Reference's First Name

Reference's Last Name

Reference's Suffix

Reference's Phone Number

How do you know this person?

If Other, please explain:

Read the Youth Committee Participation Agreement

Acknowledgement of Participation Agreement

I have read the Youth Committee Participation Agreement and I ACCEPT.
I have read the Youth Committee Participation Agreement and I DO NOT ACCEPT.

Youth Committee
Participation Agreement

I understand I am applying to become a member of the Youth Committee of the Kansas
Advisory Group. I understand if I am selected, I may serve the Youth Committee until
my 21st birthday and continue as an alumni member with the permission of the Chair.

If chosen as a Youth Committee member, I understand it will be my role and
responsibility to:
◌	Actively participate in Youth Committee meetings;
◌	Be involved in planning and attending meetings and events of the Committee;
◌	Be willing to listen to concerns and ideas of other youth in care and provide
	recommendations to the Youth Committee as a voice for youth in Kansas;
◌	Respect other's opinions and be responsible for expressing my own;
◌	Be willing to do my part;
◌	To exercise good judgment:
◌	Follow the guidelines and policies of all meetings and events;
◌	Be a leader and positive role-model at all meetings and events.

As a Youth Committee member, I will stay in contact with the Chair and promptly report any
changes in my address, phone number, or email address. I am committed to enhancing the
lives of Kansas youth through my advocacy efforts as a Youth Committee member.

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