Youth & Young Adult Engagement Advisory (YYEA) Application Form

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Please fill out the application form if you wish to become a YYEA member. If you have any issues with the online form, or any questions at all, please email Nikobi Petronelli at npetronelli@youthera.org

*IMPORTANT* - The Children’s System Advisory Council, Oregon Alliance to Prevent Suicide, Healthy Transitions Project and the Youth and Young Adult Engagement Advisory Committee are public entities and it is important that you share information with that in mind. We can talk with you further about any specifics not shared in your application. If you don’t know what this means, get in touch with us ☺

Email *

Personal Details

Date *

YYYY

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Full Name *

Date of Birth *

YYYY

Email *

Phone Number *

Address *

Are you currently enrolled in an educational program? This is not a requirement to be involved. Examples: high school, college, vocational or training program, etc.) *

If yes, please answer the following. School Name, Year in School, Major/ Field of Study.

Identities (optional)

Race/Ethnicity (can respond with multiple races/identities)

Preferred Pronouns (examples: she/her, he/him, they/them)

Do you have any other cultural or social identities or experiences you would like to share with us? (examples: LGBTQ+, Indigenous Peoples, Neurodiverse)

What services or communities do you identify with? (check all that apply) *

Addictions/Recovery

Suicide Prevention

Juvenile Justice or Adult Corrections

Education (IEP/504- Plan)

Mental Health/Wraparound/EASA

Foster Care

Homelessness/housing instability

I’d prefer not to say

Other:

Required

Why are you interested in the Youth and Young Adult Advisory (YYEA) Committee? *

Involvement Questions

What skills and/or knowledge would you bring to the YYEA Committee? *

What behavioral health* issues do you care about most? Please note that behavioral health includes topics such as mental health and addictions/recovery. *

Please check all that you are able to commit to *

Maintaining active membership for at least six months

Attending YYEA monthly meetings and other YYEA events

Keeping in touch with YYEA leadership and responding to communications in a timely fashion

Contributing to the success of the committee by participating in discussions and projects, taking on extra roles and responsibilities when needed, and keeping YYEA a safe and inclusive environment for everyone

Required

1. What types of assistance will you need to participate? Stipends and travel reimbursement are available for all meetings and events. Most meetings and events are held in Salem or Portland, Oregon. In 2020 we will begin hosting additional meetings in Lane and Douglas County for youth who reside in those areas. Advanced notice will be given for all events.

Transportation (If you do not have a personal vehicle)

Accommodations for meetings and events

Dietary restrictions/accommodations

Send me a copy of my responses.

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