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Burke Youth Health Coalition Application
Enter your contact information to receive further information about joining the B.Y.H.C.!
* Indicates required question
Youth Name (First, Last)
*
Your answer
School, Grade
*
Your answer
Youth Email Address
*
Your answer
Youth Phone Number
*
Your answer
Parent Email Address
*
Your answer
Parent Phone Number
*
Your answer
Sample Projects of Interest
*
Policy Change (Park/Merchant Assessment)
Youth Summit
Posters (Mental Health Awareness Month/National Prevention Week)
De-Stress Fest
Environmental Clean-Up Day (city/park)
Other:
Required
What was your Primary Color(s) on the Personality Test?
*
Your answer
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