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                2014    Youth Ambassador Program Application
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Contact Information
Name: *
Date of Birth: *
(mm/dd/yyyy)
Age: *
Home Address: *
Mailing Address (if different):
Does your neighborhood have a community name? *
(ex. North Side, Homewood, Squirrel Hill...)
Primary Phone Number and type: *
(ex. xxx-xxx-xxxx cell/ parent's work/ home...)
Alternate Phone and type:
Email *
Family Information:
Parent/Guardian Name *
Relation: *
Parent/Guardian Phone: *
Parent/Guardian Email
Languages Spoken at Home: *
(Please list in order of fluency)
Demographic Information
(optional)
Preferred Gender:
Race/Ethnicity:
Family Income Level
Other Information
What grade will you be in? *
If still attending school next year
What school will you attend? *
Dietary restrictions or needs?
Accommodations Required
Do you have any medical conditions we should be aware of? *
How did you find out about the Youth Ambassador Program? If a specific person told you about YAP, what is their name and title? *
Would you be interested in working with a mentor for the next 6 months? *
Written Questions
Please be thorough when answering these questions!
What skills do you have that would be relevant to your work with YAP? How did you develop these skills? *
Why do you want to be a Youth Ambassador? How do you think you would benefit from the program? *
What are the biggest problems facing young people in your community? *
What do you think the causes of these problems are?
What issue area of the Three Rivers Community Foundation are you most interested in and explain: disability rights, economic justice, environmental justice, racial justice, women/youth/families, sexual identity, peace/human rights *
 You may choose more than one
What unique perspective(s) do you feel you could bring to the program? *
Please describe one significant event, person, or experience that has helped make you the person that you are today. *
Please list the activities you will be involved in (or think you will be involved in) for this summer. Please detail the activity, duration/time commitment, position, and responsibilities. *
Involvement in other activities is NOT a requirement for the YAP program.
YAP Application Commitment Statement
By filling in the blank below with my name, I acknowledge that I have read and understood and support the mission and goals of the Three Rivers Youth Foundation and its social justice mission.   I understand that the Youth Ambassador Program entails 8 total days: 4 weekly training sessions, 3 workshops with local YMCA's, and a closing ceremony. I have also discussed the time and travel commitment with my parent(s)/guardian(s), teachers and school administration, sports coaches, and other activity directors, employers, and all others who may be affected by my involvement with the program. I commit to making the Youth Ambassador Program a top priority and to attend all (or all but one) of the workshop sessions.  I understand that when I step into school and community settings as a Youth Ambassador, younger children are looking up to me as a role model and will take cues from my behavior, whether or not I am actively facilitating a given activity. Therefore, I pledge to always demonstrate the highest standards of behavior, civility, and respect to everyone I encounter as part of the Youth Ambassador Program. *
Please type your name below in acceptance of this statement: ex. John J. Smith
Release of Legal Liability & Media Release
Parent(s)/Guardian(s) Commitment Statement:
By filling in the blank below with my name, I acknowledge thatI the parent/legal guardian understand and support the mission and goals of the Youth Ambassador Program, support my son/daughter/ward in this commitment. I grant permission for my my son/daughter to participate in all Youth Ambassador Program activities.   I also grant permission for my son/daughter/ward to be involved in the documentation of the program, including photographs, video recordings, audio recordings, reproduction of written work, and written questions. I understand that the resulting material, with or without identification of my son/daughter/ward by name, may be exhibited before the community, schools, fundraisers, or groups or individuals in furtherance work of the Three Rivers Community Foundation, its fundraising campaigns or any of its programs on behalf of communities and organizations in Southwest Pennsylvania. I am aware that this documentation material may be edited as necessary.   I also release, hold harmless and agree to indemnify the Three Rivers Community Foundation, all Board of Trustees members, staff, representatives, employees, interns, volunteers, and agents from and against any present or future claim of loss or liability for injury to person or property, related to my child’s participation in this program (including periods of transit). *
Please type your name below in acceptance of this statement: ex. John J. Smith
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