Name:
Gender	Male Female
Address
City
State / Zip	/
Phone
Email Address
Date of Birth
Grade
List groups, organizations, extra-curricular activities
List interests, hobbies, talents, and anything else about yourself
Suggestions
Parent/Guardian Name(s)
I agree to adhere to the bylaws outlined by the Youth Council. If I fail to follow these rules, I understand that my membership may be revoked.	I agree I do not agree