Youth Delegate Application 2018-2019 Survey

We invite applicants to join the 1st annual cohort of Northwest Portland Area Indian Health Board (NPAIHB) Youth Delegates. Have questions about the program? Want to learn more? Visit http://www.npaihb.org/youth-delegate/ or email tatchley@npaihb.org

If you would like to complete the application off-line as a fillable form, you can access the Application Here.

APPLICATION CLOSES: 11:59pm June 1, 2018

IMPORTANT: If you are under 18, you’ll need to have a parent or guardian sign the application when you’re finished filling it out, and before you submit it.

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* 1. Please Enter Your Contact Information

First and Last Name *

Date of Birth (MM/DD/YY) *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Mobile Phone Number *

Alternate Phone Number *

Email Address *

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* 2. Gender Identity

Male

Female

Non-binary

Two Spirit

Other (please specify)

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* 3. Shirt Size

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* 4. How did you find out about the NPAIHB Youth Delegates?

Web search

Social media

Event

Friend

Parent

Other (please specify)

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* 5. If you are in school, which school will you attend next year (Fall 2018)?

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* 6. What grade will you be in next year (Fall 2018)?

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* 7. If you are not in school next year, list your plans for Fall 2018:

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* 8. Are you an enrolled tribal member or a descendant of one of the 43 NPAIHB Member Tribes (Federally Recognized Tribes in Idaho, Oregon, or Washington)?

Yes

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* 9. Please list the following or indicate N/A:

Tribe

Reservation

Enrollment Number/Blood Quantum