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Youth Advisory Council Application -page 3- <br />6. What are some personal skills which you would like to be enhanced from this experience. <br />7. List the name, address & phone number of your two (2) adult references unrelated to you. <br />I have completed this application with accurate information and wish to have it considered for a <br />Youth Member position on the Youth Advisory Council of the City of South Bend, Indiana. If <br />selected, I will make the necessary personal and time commitments necessary to serve the youth <br />of our community. <br />Youth signature Date <br />Parent/Legal Guardian Permission/Release: <br />I give my permission for my son/daughter to seek the position of a Youth Member to the Youth <br />Advisory Council of the City of South Bend, Indiana. If selected, I will make sure that my <br />son/daughter will make the necessary personal and time commitments necessary to serve the <br />youth of our community. I further understand that as a member of the Youth Advisory Council <br />my son/daughter may have photos, film, digital imaging, videos, verbal and written statements <br />of his or her likeness for promotional, web usage or other uses associated with the Youth <br />Advisory Council. To that end, I grant permission for such usage. <br />ParentlLegal Guardian signature Date <br />Name and telephone number in case of emergency: <br />Date Received by the Office of the City Clerk: <br />(File-Mazk) <br />Date Sent by the Office of the City Clerk to: <br />Principal <br />District Council Member <br />At Lazge Council Members (3) <br />Mayor <br />