Youth Advisory Panel - Nomination Form
Youth Advisory Panel - Nomination Form - Word (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) ___________________
Name and Contact Information of Person Nominating Student
Name _________________________________________ Title ______________________
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