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Salem Youth Commission Application
Should you have any questions regarding the Salem Youth Commission or Application, please contact Laura Assade, Director of Constituent Services at 978-619-5601, or Lassade@salem.com.
Para español, clic en el botón en la esquina superior derecha y clic en español.
Name
First Name
Last Name
Todays Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
Emergency Contact Relationship to you
How did you hear about the Youth Commission?
Why would you like to join the Youth Commission?
Please check the Ward you live in:
Ward 1- Councillor Robert K. McCarthy
Ward 2- Councillor Christine W. Madore
Ward 3- Councillor Lisa JB Peterson
Ward 4- Councillor Timothy G. Flynn
Ward 5- Councillor Josh H. Turiel
Ward 6- Councillor Beth Gerrard
Ward 7- Councillor Stephen G. Dibble
To find out what ward you live in, you can visit wheredoivotema.com and type in your address
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Education
In lieu of answering the following questions, please submit a resume if possible.
School Name
Grade
GPA
Expected Date of Graduation
-
Month
-
Day
Year
Date
Please list all of your extracurricular activities (sports, clubs, hobbies, jobs, volunteering, etc.
What special skills or talents would you bring to the Youth Commission?
List any honors and awards
Career Plans
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Certification
I certify that the information provided above is complete and accurate to the best of my knowledge. I understand that giving a false answer to any question or withholding or omitting any information requested, may be grounds for denial of this application and/or dismissal from the Youth Commission program.
Name
First Name
Last Name
Todays Date
-
Month
-
Day
Year
Date
Photo Release:
I grant The City of Salem Youth Commission & its representatives the right to take photographs of me and my property in connection with the above-identified subject. I authorize Salem Youth Commission, its assigns and transferees to copyright, use, and publish the same in print and/or electronically. I agree that the Salem Youth Commission may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. I have read and understand the above.
Name
First Name
Last Name
Todays Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: