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2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
12. School Attending
14. Current Grade
15. Date of Birth
17. Name of Parent/Guardian
18. Are you a City of Portage resident?

    1. Yes
    2. No
20. Besides school, what other activities do you participate in (e.g., sports, volunteer/paid work, drama, etc.)?
22. Why are you interested in participating in the Youth in Government Program?
24. What unique perspective are you able to offer if selected to participate on the Youth Advisory Committe or as a Youth Participant to a Board, Commission or Committee?
26. Which area(s) are you interested in serving on? (You may check more than one.)

    1. Youth Advisory Committee
    2. Youth Participant to Environmental Board
    3. Youth Participant to the Historic District Commission
    4. Youth Participant to the Human Services Board
    5. Youth Participant to the Park Board
    6. Youth Participant to the Senior Center Advisory Board
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field