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2. Student Last Name
3. Student First Name
5. Street Address
7. City
8. State
9. Zip Code
11. Student Cell Phone Number
12. Email Address (primary form of student communication)
14. Birthdate
15. T-Shirt size
16. Allergies or Medical Conditions
18. School
19. Current Grade
20. Current School Year
22. Primary Parent/Guardian Name
24. Primary Parent/Guardian Email (primary form of adult communication)
26. Primary Parent/Guardian Phone number
28. Parent/Guardian interested in volunteering?

    1. Yes
    2. No
30. Emergency Contact Name (if different from above)
31. Emergency Contact Phone (if different from above)
33. What activities have you been involved with in the community?
35. What are the ideas and goals that you have for this community?
37. What qualities or skills can you bring to YAC?
39. List other organizations/clubs you are currently a member of.
43. By checking the "agree" box below give my child permission to participate in City of Killeen Youth Advisory Commission (YAC)/Junior YAC (JYAC) activities or events, October 1, 2023 through September 30, 2024. I agree that I will waive any right of contribution and shall indemnify and hold harmless the City of Killeen and its elected officials, officers and employees, and the Youth Advisory Commission, both in their public and private capacities from and against all claims, damages, losses and expenses, including but not limited to attorney’s fees arising out of our resulting from or in connection with my child/ward’s behavior or action, and my behavior actions. This waiver is intended to cover all acts or omissions of the City of Killeen, and its elected officials, officers and employees, regardless whether such act or omission is the result of an intentional, reckless, grossly negligent act. By signing this waiver, it is my intent to bind my heirs, executors, administrators and assigns. I further agree and will not hold the City of Killeen or the Youth Advisory Commission liable in case either of us is injured or involved in any type of accident. I further agree and represent that no promise, inducement, or agreement not herein contained or expressed has been made to me, and that this release contains the entire agreement between the parties, hereto, and that the terms of this release are contractual and not merely a recital. I agree that City of Killeen, its officials, employees, agents, and representatives have the authority to use pictures of my child taken during his/ her participation in the Youth Advisory Commission. The pictures may be taken and used without my knowledge or payment to me. In case of an emergency, I grant permission for a licensed physician to treat my child. I have read this document and understand all its terms and contents. I execute it voluntarily, and I specifically affirm and warrant that I fully understand all matters set forth herein.

    1. I agree
    2. I disagree
45. Photo/Video Release Form*

     By checking the “agree” box below you grant the City of Killeen, its agents and assignees permission to use your likeness in a photograph or video in all of its publications, including web site entries and social media platforms without payment or any other consideration. You understand and agree that any photographs or videos taken will become the property of City of Killeen and will not be returned. You hereby irrevocably authorize the City of Killeen, its agents and assignees to copy, exhibit, publish, or distribute these photos and videos for the purpose of publicizing the City of Killeen Youth Advisory Commission or any other lawful purpose. Additionally, you waive any right to royalties or other compensation arising or related to the use of either photos or videos.

    1. I agree
    2. I disagree
49. Electronic Signature Agreement*

    By checking the "agree" box I grant the Youth Advisory Commission to identify my student with their full name in the aforementioned communications.

    1. I agree.
51. Applicant's Electronic Signature
53. Parent/Guardian Electronic Signature
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55. Submit

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