Thank you for joining the Healthy Youth Coalition!  Please complete the following form so we have the most up-to-date information and you can receive news and meeting reminders in the most beneficial way.  Please return completed form to the coalition at 1201 41st Avenue, Menominee, MI  49858 or fax to 906-863-7776

Please PRINT clearly:

Name: ______________________________________

Organization or School: ________________________________


Address (please include all addresses where you receive mail, or choose the one you would like us to send you HYC information):

________________________________________City________________________ State: _________ Zip: ___________

Address #2 (optional):______________________________________________________________________________

City_________________________________________________________ State: _________________ Zip: __________


Cell (optional):_____________________________

Are we allowed to contact you through text: ______

E-mail address: ____________________________________


Which one are you? (Circle ONE)


Youth                                                   Parent                                       School Employee


Civic Group Member                              Healthcare Provider                   Business Community Member


Media                                                   Law Enforcement                      Youth Serving Organization

Local Government Agency                     Religious Organization               Other__________________

If you are a student, what is your graduating class?____________________________________

Please check you preferred method of receiving communications:


__________U.S. Mail                 __________E-mail         __________Phone


I hereby give my consent to all photographs, audio recordings, and/or video recordings taken of me or my minor child by The Healthy Youth Coalition of Marinette and Menominee Counties staff or their designee. I understand that any such photographs, audio recordings, and/or video recordings become the property of the Healthy Youth Coalition and may be used by the coalition or others with their consent, for educational or promotional purposes determined by the coalition in broadcast and electronic media formats now existing or in the future created.

(Please check one of the options below.)

Date: ______________                                       ______ Yes, I give my consent   ______ No, I do not give my consent

Parent’s/Guardian’s Name: ___________________________

Signature: ______________________________________

(Parent/guardian signature)

Mailing Address: ___________________________           City:_____________________     State:________ Zip:_______

Telephone: _________________________

E-mail Address: _____________________________________