2. 

3. Portage Youth Commission

   Membership Application

   *Applicants must be entering 8th - 12th grade

5. Name:*
6. Email *
8. Address, City, State, Zip*
9. Phone Number*
11. Birthdate*
12. School Name and Grade level*
14. Applicant Experience:​

    List any recent job, volunteer,  or organization/club experience you have and the length of time involved in each.

16. List One Reference:*
17. Contact email:*

19. Additional Information:

    In order to better understand your views and ideas for the Youth Commission, please respond to the following questions.

21. What do you envision the role of the Portage Youth Commission in local government? How can it benefit the city?
23. In your opinion, what is a critical issue facing youth in your school, neighborhood and/or city? How would you utilize the Youth Commission to help resolve this issue?

25. Application Statement

    I hereby certify that the information i have provided is true and correct to the best of my knowledge. I understand that provision of false information may disqualify my consideration. I authorize the release of this information for verification purposes and understand it will be used only to process my application.

27. Signature*
28. Date
30. 

31. Return completed application to:

    nlaboy@portage-in.com or mail to:

    Portage Youth Commission

    Portage City Hall, 6070 Central Avenue

    Portage, IN 46368

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