YS - Future Leaders Sign Up

If you are interested in leadership, community service hours and job opportunities; joining Future Leaders United for Change.

For more information call (561) 242-5737 or email YSD-Future-Leaders@PBCGOV.ORG

Youth Information:

First Name *This question is required.

Last Name *This question is required.

Address Line 1 *This question is required.

Address Line 2

City

State

Zip

Home Phone *This question is required.

Cell Phone *This question is required.

Email *This question is required. This question requires a valid email address.

Current School *This question is required.

Gender *This question is required.

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

How did you find out about Future Leaders?

Agency Address

Address Line 1

Address Line 2

City

State

Zip

Agency Contact Person

First Name

Last Name

Contact Person Phone

Contact Person Email This question requires a valid email address.

What would you like members to know about you? *This question is required.

Parent or Legal Guardian's Name

First Name

Last Name

Phone Number

Email

Parent or Legal Guardian's Name

First Name

Last Name

Phone Number

Email

Participant Signature (if over 18 years old)

Clear

Signature of

Disclaimer: Employees and/or Representatives of Palm Beach County Youth Services Department (the County), or others, may take photographs and/or record videotapes, audiotapes, or other recordings (collectively Photographs and Recordings) that include images and/or the voice of minors who participate (the Participant) in Palm Beach County Youth Services Department activities, services and events.the Participant, and our respective heirs, successors, and assigns: (i) hereby releases and waives any and all interest we may have in and with respect to all Photographs and Recordings; (ii) grants the County permission, but in no way requires the County, to use the Participant’s name and identifying information in connection with such Photographs and Recordings; (iii) agrees that the Photographs and Recordings are the sole and exclusive property of the County and that the County may, without payment to the Participant or anyone else of any consideration whatsoever, take, make, edit, enhance, revise, and use the Photographs and Recordings in any medium and for any purpose whatsoever, including but not limited to education, training, advertising, web content, public information, and news and social media; and (iv) hereby and forever releases and discharges the County and its officers, employees, administrators and representatives from any and all claims, demands, rights, damages, costs, expenses, compensation, actions, causes of action or suits of any kind or nature whatsoever, now known or later discovered, for, among other things, invasion of privacy, right of publicity, and defamation arising out of or in any way related to the Photographs and Recordings and the County’s use thereof. This Consent and Release may be revoked by me in writing, and if revoked shall apply to use of Photographs and Recordings subsequent to the revocation only. I HAVE READ THIS CONSENT AND RELEASE, I FULLY UNDERSTAND ITS TERMS, AND I AM SIGNING THIS CONSENT AND RELEASE FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE OR GUARANTEE BEING MADE TO ME.

Parent/Guardian Signature

Clear

Signature of

Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.

YS - Future Leaders Sign Up

FUTURE LEADERS UNITED for CHANGE