MEMBER INFORMATION
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: __________
Phone:___________________________
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
MEDIA RELEASE
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: _____________________________________
