APPLICATION FORM

Spoken languages: Written languages: Name of the school you presently attend: What grade are you completing this year ? EXTRA-CURRICULAR ACTIVITIES :.
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APPLICATION FORM

YOUTH ACTION COMMITTEE Name:_

First name:

Address:

Postal code :

Telephone:

Cell : _

E-mail :

Spoken languages:

Written languages:

Name of the school you presently attend:

What grade are you completing this year ?

EXTRA-CURRICULAR ACTIVITIES : ACTIVITIES/COMMITTEES

DUTIES

YEAR

______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ HOBBIES: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

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How many hours per month are you willing to give to the committee? _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

What time is the best time for you to attend committee meetings? _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

____________________________________________________________ Signature of applicant:

_____________________________

Date

____________________________________________________________

_____________________________

Signature of parent: Date

FOR USE OF THE CITY OF DIEPPE Date received : _________________________________________________________________________________ By: _________________________________________________________________________________________

For further information : Sonya Babineau, Community officer – Community groups and Youth sectors 333, avenue Acadie Dieppe NB 506-877-7831• [email protected]

The personal information on this form is collected under the authority of the Right to Information and Protection of Privacy Act (RTIPPA) and the Personal Health Information Privacy and Access Act (PHIPAA). The information can be used when required by law. Please contact the City Clerk’s Office at 877.7900 if you have any questions about this gathering of information.

75LIR08.15v1EN