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2. Application Information
4. First Name*
5. Last Name*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Home / Cell Phone*
14. Email Address*
16. Emergency Phone
20. Why do you wish to participate in the Community Council?*

24. I will be available to attend meetings the 3rd Friday of the month from 11:00 a.m. – 1:00 p.m. Attendance is required to earn a certificate at the end of the program. The program is scheduled to end on December 31, 2023.

30. Please give the name, address, phone number, and email of two character references:
32. First Name*
33. Last Name*
35. Address*
37. City*
38. State*
39. Zip Code
41. Phone Number*
43. Email Address*
45. First Name*
46. Last Name*
48. Address*
50. City*
51. State*
52. Zip Code
54. Phone Number*
56. Email Address*
58. Applicants are required to be at least 18 years of age and a simple background check will be completed prior to the program beginning.
60. Date*
    Date
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62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit Submit and Print

* indicates a required field