Open Up Mississippi Membership Form 

 

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


Sign in to Google to save your progress. Learn more
What is your first name? 
What is your last  name? 
What is your date of birth?  (00/00/0000)
What is your street address?
What is your city, state, and zip code?
What is the best number to contact you? (include area code)
What is the best email to contact you?
What school/college/university are you attending? (if applicable) 
What  is your grade/classification in school/college/university? (if applicable) 

Please indicate which category applies to you - check all that applies:

Are you a member of another youth council?

Clear selection

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 12/20/23?

Clear selection

How did you find out about Open Up Mississippi?

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?

Clear selection

Parent/Guardian name

Best contact number for Parent/Guardian

Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms