Form Center

2. Name
3. Email Address
5. Street Address
7. City
8. State
9. Zip Code
11. Primary Phone Number
12. Secondary Phone Number
14. Gender
15. Ethnicity
16. Birth Date
18. School
19. Current Grade
20. Current School Year
22. Employer (if any)
23. T-shirt Size
25. Parents' Names
26. Parents' Phone
28. Parents' Email
30. What activities have you been involved with in the community?
32. What are the ideas and goals that you have for this community?
34. What qualities or skills can you bring to YAC?
36. List other organizations/clubs you are currently a member of.
38. Has either of your parents served in the military?
39. If so, are the active duty or retired?
43. Photo/Video Release Form
45. I grant the City of Killeen Youth Advisory Commission permission to reprint my photograph and/or my son or daughters’ photograph and to use video of my son or daughter for Youth Advisory Commission publications, Web sites, electronic and digital media, publicity, advertising and/or the calendar. All photographs/videos will remain the property of the City of Killeen Youth Advisory Commission.

    1. I agree
    2. I disagree
47. I grant the Youth Advisory Commission to identify my son or daughter with their full name in the aforementioned communications.

    1. I agree
    2. I disagree
51. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
53. Applicant's Electronic Signature
55. Parents' Electronic Signature
Leave This Blank:


57. Submit

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