Contract Instructor Payment Request

Name * (required)

Home Phone * (required)

Cell Phone

Email * (required)

Address * (required)

City * (required)

Zip Code * (required)

Parent/Guardian Name * (required)

Work/Cell Phone

Years lived in Dana Point * (required)

High School * (required)

Senior
Junior
Sophomore
Freshman

Briefly state why you want to be a member of the Youth Board, and what skills or abilities you have that would contribute to its success. Please be specific. * (required)

Please list school or community activities in which you are involved. * (required)

References: Provide two references not related to you, that have first-hand knowledge of your character, personality and general ability (Name, address, and phone number).

1) * (required)

2) * (required)

I understand that information on this form may be verified and released, and that some details may be given to the media. I consent to the Dana Point Youth Board using and publishing my/my student’s name, image, likeness, and related information in print, electronic, web, and other media indefinitely. Materials may be edited for format or delivery, and I understand posted content may be publicly accessible and copied by anyone with access to the internet.

By typing your name below, you are electronically signing this document and agreeing to the statement above.

Student's Signature

DateDate

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Parent's Signature (if under 18)

DateDate

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