Open Up Mississippi - Member Application
OPEN UP Mississippi is a statewide youth lead advisory council with a mission to engage youth and young adults as they break down barriers to gain mental  wellness  and  utilize  their  strengths  and voice against the stigma of mental health.  Individuals completing this form should be between the ages of 14 - 26.  For additional information, call 601.899.9058
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First Name
Last Name
Date of Birth
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Street Address
City and State
Zip Code
Best number to reach you
Best email address to reach you
Currently attending what School/College/University
Current grade/classification in School/College/University
Please indicate which category applies to you:
Are you a member of another youth council?
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If yes to the above question, note the name of the youth council.
Are you able to commit to be an active member of the council through 12/2021?
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How did you find out about Open Up Mississippi?
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Please check the following skills you are able to offer to the council OR you are interested in developing as part of the council:
If under the age of 18, is a parent/guardian aware that you are applying for membership with Open UP Mississippi?
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Parent/Guardian Name
Best contact number for Parent/Guardian
Why is mental health important to you?
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