2021-2022 Youth Ambassador Application Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth* MM slash DD slash YYYY Email* Email will be the primary form of communication for this group. Please list one that you check on a regular basis!Shirt Size* Grade Level for 2021-2022 School Year* Approximate current GPA* School Name* School Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code School Phone*Hometown Newspaper* Please upload a head shot or school photo to be used on ACT Missouri's website and social media channels, as well as press releases if you are chosen.*Max. file size: 300 MB.Student AgreementBy submitting this application, I agree to serve as a Youth Ambassador to the best of my ability for a one-year term by attending the required events (including Google Hangout meetings and trainings), providing a prevention training in my community, and adhering to the roles and responsibilities explained on the ACT Missouri website. I certify that I have provided complete and accurate statements on this application. *Note: Initialing below serves in the same capacity as your personal signature. Initials* Date* MM slash DD slash YYYY Activities and Accomplishments*Max. file size: 300 MB.Upload a list of your activities and accomplishments that support your application, including, as appropriate, dates of service or award. If you have a résumé with comparable information that adequately highlights or explains your qualifications for the Youth Ambassador Program, you may submit it in place of the form. Please submit no more than two pages. Some sample elements of your list could be: SADD Activities, School Activities, Community-Service Activities/Volunteer Work, Employment History (if applicable), Hobbies/Activities/Sports, Special Awards and Recognitions/Honors, Other Accomplishments.Short Essay: Why is drug and alcohol prevention important to you and your community?*Max. file size: 300 MB.Answer the following question briefly and succinctly, less than one page single spaced. We encourage you to use examples or anecdotes to illustrate your points. Parent/Guardian ConsentACT Missouri understands the importance of parental involvement in their child’s interests and community involvement. For this reason, we are requesting that you review all of the provided materials and then fill out this permission slip. A parent/guardian or sponsor will be copied on all email communication. If you have any questions, or require additional information, please contact the ACT Missouri office at (573) 635-6669.Name* First Last Work Phone*Cell Phone*Work Email* Personal Email* Relationship to Applicant* Additional Emergency Contact (not you)* First Last Emergency Contact Phone*Relationship to Applicant* Parent/Guardian AgreementI have read and discussed all materials and criteria with my child. I give my child permission to participate in the Youth Ambassador Program and I verify that the information of which I have personal knowledge is complete and accurate. I authorize ACT Missouri to use the name and/or photograph of my child for promotional and/or publicity purposes surrounding Youth Ambassador activities. I understand that my child is required to have a chaperone accompany him or her to each Youth Ambassador training and activity. If that isn’t me, I will send an appropriate chaperone in my place. *Note: Initialing below serves in the same capacity as your personal signature. Signature*Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.