Special Education

Youth Advisory Panel - Nomination Form

Youth Advisory Panel - Nomination Form - Word Word Document (37 KB)

Please use this form to nominate a student with a disability to the New York State Education Department’s Youth Advisory Panel.  The student must be currently attending high school or have exited high school within the last two years (former student nominees are not required to have graduated with a Regents or local diploma).  *Youth who are 18 years of age or older may use this form to nominate themselves. 

(Please Type or Print)

Name of Student       Last Name __________       First    ___________                              Middle

Date of Birth                    /           /          
Month     Day    Year

Gender     __ Male __Female

Name of School and School District __________________________________

Grade or Year _____________________________

Student’s Mailing Address
Street/P.O. Box ______________________________________________
City ________________________          State   __________           Zip __________

Telephone  (Home)______________________     (Cell)    ___________________     

Email __________________________

Name and Contact Information of Person Nominating Student

Name _________________________________________ Title ______________________
Telephone __________________________________
Email ______________________________________

Briefly describe why you recommend this candidate for the Youth Advisory Panel.



___ Check this box if written parent consent has been obtained for this student to participate, if selected, in the Youth Advisory Panel.

Name                                                             Signature                                              Date

Last Updated: March 6, 2014