Form Center

2. Instruction

   Fill out this form.

3. Date: *
   Date:
5. Student's First Name*
6. Student's Last Name*
8. Student's email:*
9. Student's cell phone#:*
11. Address:*
12. City: *
13. Zip code:*
15. Race/Ethnicity (optional)
    -- Select One --American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative HawaiianWhitePacific Islander
17. High School:*
18. Graduation year: *
19. Birthdate:*
21. Parent/Guardian First Name*
22. Parent/Guardian Last Name*
24. Parent/Guardian Email:*
25. Parent/Guardian Phone#:*
27. School extra-curricular activities:
28. Community extra-curricular activities:
29. Special awards/recognition:
31. 1. What skills or characteristics do you possess that make you a good representative for youth?*
33. 2. What three issues do you feel need to be addressed in Holland?*
35. 3. Select one of your issues and briefly explain how you, city agencies and residents can address this concern effectively.*
37. 4. What special skills do you believe that both you and youth in general can bring to our community's decision-making process?*
39. 5. What other activities do you plan to be involved in throughout the school year?*
41. 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.
43. Downtown Development Authority*
44. Human Relations Commission*
45. Neighborhood Improvement*
47. Parks and Recreation*
48. Historic Planning Commission*
49. Planning Commission*
51. Macatawa Area Express Advisory (Max Transit)*
52. International Relations Commission
53. West Michigan Airport Authority
55. Teen Court
56. Police/Community Relations
57. HYAC Social Services Committee
59. HYAC Core Council
60. HYAC Environmental Committee
61. HYAC Recreation Committee
63. First Choice
    -- Select One --Downtown Development Authority*Human Relations Commission*Neighborhood Improvement*Parks and Recreation*Historic Planning Commission*Planning Commission*Macatawa Area ExpressAdvisory (Max Transit)International Relations CommissionTeen CourtPolice Community RelationsWest Michigan Airport AuthorityHYAC Core CouncilHYAC Environmental CommitteeHYAC Recreation CommitteeHYAC Social Services Committee
64. Second Choice
    -- Select One --Downtown Development AuthorityHuman Relations CommissionNeighborhood ImprovementParks and RecreationHistoric Planning CommissionPlanning CommissionMacatawa Area Express Advisory (Max Transit)International Relations CommissionTeen CourtPolice/Community RelationsWest Michigan Airport AuthorityHYAC Core CouncilHYAC Environmental CommitteeHYAC Recreation CommitteeHYAC Social Services Committee
65. Third Choice
    -- Select One --Downtown Development AuthorityHuman Relations CommissionNeighborhood ImprovementParks and RecreationHistoric Planning CommissionPlanning CommissionMacatawa Area Express Advisory (Max Transit)International Relations CommissionTeen CourtPolice/Community RelationsWest Michigan Airport AuthorityHYAC Core CouncilHYAC Environmental CommitteeHYAC Recreation CommitteeHYAC Social Services Committee
67. 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.
69. Name of school official for reference: *
71. Email address for reference:*
73. 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.

    1. I agree.
75. Parent/Guardian Electronic Signature*
77. If you have any questions, please contact Joan at j.mccluskey@cityofholland.com
Leave This Blank:


78. Submit Submit and Print

* indicates a required field