Healthy Minds Fairfax Youth Advisory Council

School and Work
Are you enrolled in school, Certificate Program, GED Program, or Post-Secondary Education?*

YesNo
If yes, what school are you attending?
Do you have an IEP or 504 plan at school? Or did you when you were in school?*

YesNoDoes not apply
Do you have a job(s)?*

YesNo

Long Answer
Have you ever been involved in any systems? Please check all that apply*

Juvenile JusticeFoster Care/ Child WelfareMental/Behavioral Health TreatmentSubstance Use TreatmentHomeless Services and SupportsSpecial/ Alternative EducationResidential ProgramOther
What do you consider some of your skills and strengths? For example, what things do you find yourself being asked to do for friends, neighbors, and family?*
What is one thing you would like to change about the agencies and organizations that serve youth and young adults?*
Why are you interested in serving on a Youth Advisory Council? (For example, are you interested in getting to know other young people with similar life experience? Are you excited for a chance to advocate for change or something else?)*
Is there anything else you would like to share about yourself that was not covered in these questions?

Accessibility
Do you need language interpretation?*

NoSpanishASLArabicOther
How do you access transportation?*

CarPublic TransportationUber/ Lyft or another Ride Sharing AppOther
Are there any other barriers that would prevent you from being involved in the Youth Advisory Council?

I, First Name* Last Name* , attest that I have answered these questions honestly and understand that I can call or email the Youth Development Coordinator at 301-335-2028 or mstewart-boldin@jssa.org if I need any accomodations to complete the application or if I have any questions.
Clear
Should be Empty:

Youth Advisory Council Application