San Bernardino County Tobacco Control Program

Youth Advisory Coalition Participation Form

Youth Advisory Coalition

The San Bernardino County Tobacco Control Program (SBCTCP) Youth Advisory Coalition was established to ensure students have an opportunity to take the lead and create meaningful change in their communities in tobacco control efforts. Youth Advisory Coalition members will be provided with fun, innovative training on tobacco prevention, leadership skills, public speaking, data collection, policy/advocacy work, working with elected officials and social norm change. Using these skills, advisory board members will be assisted in planning and organizing their own tobacco control efforts in their respective communities on the issues of tobacco-free outdoor recreation areas and healthcare facilities and/or zoning and density of tobacco retailers.

Qualifications

All youth members must be:

13-18 years old
Be able to attend meetings as needed
Attend high school, have regular attendance and be in academic well standing
Be able to work as a team

Responsibilities

Coalition Member’s responsibilities include:

Attend meetings twice a month and events
Participate in trainings
Attend 80% of meetings
At least once a year present with staff or peers to local community organizations, city council members, city staff, or state legislators on coalition efforts
Attend and volunteer at 1 community event/project

Incentives to Participate

By participating, youth will receive:

Leadership training
Understanding of local politics
Incentives during meetings including promotional gear and snacks
Opportunity to attend a Youth Leadership Summit
Letters of recommendation for university applications, employment and other programs
Opportunity to fulfill volunteer / community service hours

Participation Form

Student Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone*
Cell Phone*
Name of School*
Grade (if applicable)
Date of Birth*
Date Format: MM slash DD slash YYYY
Email*
Parent/Guardian Information
Name*
First Last
Relationship*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone*
Cell Phone*
Email*
Consent to photograph, audio, or videotape a student for non-profit use*
I Agree
I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, audio or video of the student named above by the California Health Collaborative, San Bernardino County Tobacco Control Program. I also grant to the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release the California Health Collaborative, San Bernardino County Tobacco Control Program, and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.
Transportation and Liability Release*
- I do not want California Health Collaborative staff to transport my child
- California Health Collaborative staff may transport my child to and from program related events/activities
I give permission for the student to participate in the San Bernardino County Tobacco Control Program Youth Advisory Coalition. I agree I will not hold the California Health Collaborative, California Department of Public Health, and/or my son/daughter’s High School, their employees, or agents responsible for any injury or sickness my child may incur during this program. I also confirm my decision listed above to allow/ not allow (mark one) my child to be transported by California Health Collaborative staff during the school year. I agree I will not hold the California Health Collaborative, California Department of Public Health, and/or my son/daughter’s High School, their employees, or agents responsible if I decide to allow them to transport my child for program activities or events.
Email
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San Bernardino County Tobacco Control Program

Youth Advisory Coalition Participation Form

Participation Form

Student Information

Parent/Guardian Information

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