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2. First Name*
3. Last Name*
5. Address*
7. City*
8. State*
9. Zip*
11. Phone*
12. Email Address*
14. Date of Birth*
16. School*
17. Grade*

    1. 9
    2. 10

    1. 11
    2. 12
19. Extracurricular Activities*
21. I want to serve as a member because (check all that apply):*

    1. I am interested in learning more about the City of NRH.
    2. I would like to be heard on issues affecting the City of NRH.
    3. I would like to help plan events for the youth of NRH.
    4. Other reasons (insert reason below)
23. If you answered Other Reasons above, please indicate reason here:
25. Ideas and goals that you have for this community: *
27. How do you feel that you can contribute:*
29. What do you feel are the critical issues facing youth in NRH:*
31. Are there other youth that you would like to nominate for Youth Advisory Committee? Please include name, contact phone # and address:
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field