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HYAC Application 2021-2022

  1. Instruction
    Fill out this form.
  2. Preferred Commission Assignments
    HYAC members serve on either one City Board/Commission or a HYAC committee. Click on the links below to learn more about the work of each Board or committee. Select your first, second, and third choices via the drop down lists. NOTE: * Denotes City residency required.
  3. Statement of Consent:*
    By checking the box, I hereby certify that all statements on this volunteer application are made truthfully and without evasion, and further understand and agree that such statements may be investigated and, if found to be false, will be sufficient reason for not being appointed or may result in dismissal.
    I authorize the references listed on this application to give the City of Holland any and all information concerning my educational accomplishments, disciplinary information or any other pertinent information they may have, personal or otherwise, and release all parties from all liabilities for any damages that may result from furnishing same to you. I hereby waive written notice that employment information is being provided by any person or organization.
    In accordance with ADA requirements, if I require an accommodation to perform my duties, I must notify the Youth Services Specialist of that need within 180 days after I know or reasonably should have known that an accommodation was needed. Failure to do so will bar me from alleging that the City of Holland has not accommodated me as required by law.
    I hereby authorize the City to secure criminal conviction history from the appropriate law enforcement agency, should the City determine it is necessary to do so.
    I hereby authorize the City to use all photos and my name for publication of News, articles and Media and waive the opportunity to inspect or approve photographs or videos. I release the City, their officers, directors, agents, employees and those acting under their authority, from all debts, claims, and liability of any kind arising out of or in connection with the use and publication of the name and photograph.
  4. Parental/Guardian Electronic Signature Agreement*
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  5. If you have any questions, please contact Joan at j.mccluskey@cityofholland.com
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