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Home
What We Do
- Youth Prevention Ambassador
Events & Resources
About
- Get Involved
- News & Tips
Contact
Donate

Youth Prevention Ambassador Application

If you have any questions about this project, please feel free to contact Susan Metzger at susan.metzger@drugfreepickaway.com.

Name(Required)

First Last

Grade(Required)

Freshman

Sophomore

Junior

Senior

School(Required)

Address(Required)

City ZIP Code

Phone(Required)

Can text?(Required)

Yes

No

Email(Required)

Preferred T-shirt Size(Required)

Small

Medium

Large

X-Large

What is the best method to contact you?(Required)

Phone

Email

Text

What types of incentives would encourage you to participate in meetings and activities for the Youth Prevention Ambassadors?(Required)

Gift cards

Letter of recommendation

Volunteer/community service hours

Other

Please list other incentive(s)

Student Personal Insight

As a Youth Prevention Ambassador, your opinions and ideas about prevention are extremely important to us. Please take a few moments to answer the following questions.

Think of an issue your community is facing as it relates to youth wellness, health, safety, rights & responsibilities. State the issue and describe why it is important to you. How would you go about educating your community, advocating for and creating change around this issue?(Required)

What skills or knowledge do you hope to gain as a Youth Prevention Ambassador?(Required)

Parent/Guardian Information

Your parent or guardian must complete this section of the application.

Name(Required)

First Last

Relationship(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Cell Phone(Required)

Work Phone

Email(Required)

Parent/Guardian Permission

Photography Permission(Required)

YES, I give permission to have my child photographed or videoed during YPA activities. I understand that these photos/videos may be used for the creation of social media or other publications to promote the YPA committee.

NO, I do not want my child photographed/videoed.

Pickaway Addiction Action Coalition may photograph Youth Prevention Ambassador (YPA) members during YPA meetings or other activities. These photographs/videos may be used for social media and/or publication to promote the YPA team.

Allergies or Other Restrictions

Please indicate if your child has any allergies or health concerns that the YPA coordinator should know about.

Consent(Required)

I permit my child to participate in the Youth Prevention Ambassador team and attend meetings and activities during the school year. I understand that my child must transport themselves or find their own alternative transportation to the meetings.

Parent/Guardian Signature(Required)

Address 770 North Court St, Circleville, OH 43113

Email info@drugfreepickaway.com