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2. Thank you for your interest in our Youth Leadership Program for ages 14-18!

   
   This information will be collected and sent to the Assistant Region Manager of the Northwest Region of the Washington State Parks and Recreation Commission in order to select members for this new program for the 22/23 school year.  

   *Selected participants will be notified by email.

   NOTES 

   • Parental and/or guardian permission will be required for participation in our Youth Leadership Program 
   • Please fill in the "Reply Email" AND check "Receive email copy of this form" and fill in your email address again before you click "SUBMIT"  to have a copy of this form sent to your email

   For further information you may contact:

   John Keates
   Assistant Northwest Region Manager -- Washington State Parks
   220 N. Walnut St.
   Burlington, WA 98233

   Email: john.keates@parks.wa.gov
   Phone: Office - (360) 755-9231 Cell - (call or text) 360-899-8268

4. First Name*
5. Last Name*
6. Preferred Pronouns
8. What is the name of your school?*
9. What is your grade level?*
11. What is the address of the school you attend?*
13. City
14. State
15. Zip
17. Which of the following best describes your gender?

    Check all that apply

    1. Man
    2. Woman
    3. Genderqueer/Non-binary
    4. Not sure/prefer not to say
    5. Open response - use box below
18. How would you describe your ethnicity?

    Check all that apply

    1. American Indian or Alaska Native
    2. Asian or Asian-American
    3. Black or African-American
    4. Hispanic or Latino
    5. Middle Eastern or North African
    6. Native Hawaiian or Other Pacific Islander
    7. White/Caucasian
    8. Not sure/prefer not to say
    9. Open Response - use box below
19. What is your age?*

    1. 14
    2. 15
    3. 16
    4. 17
    5. 18
21. Use this box if you chose "Open response" in the gender question above
22. Use this box if you chose "Open response" in the ethnicity question above
24. Do you identify with any of the following communities?

    Check all that apply

    1. LGBTQIA+ people (lesbian, gay, bisexual, transgender, queer/questioning, intersex and/or asexual)
    2. Immigrant or first-generation Americans
    3. People who speak English as a second language
    4. People who use Americans with Disabilities (ADA) accommodations such as ramps, service animals, Braille or large-print, sign language, or other assistive technologies
    5. People who have experienced the foster care system (current and former foster children, foster parents, and/or kinship caregivers)
    6. Open response - use box below
26. Use this box if you chose "Open response" in the community identity question above
28. In a short paragraph, please tell us why you are interested in participating in our Youth Leadership Programs*
30. Reply Email*

    Please provide an email address so that we may send you information on our youth programs.

Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field