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Prevent Teen Pregnancy

Youth Leadership Team

Youth Leadership Team Application - Candidate Information
Deadline: May 31, 2013

First name
Middle name
Last name
Age
Date of birth (MM/DD/YYYY)
Gender	Male Female
Race	African American Caucasian Native American Asian Hispanic/Latino Mixed
Street address
Apt. #
City
ZIP
Daytime phone
Evening phone
Cell phone
E-Mail address
Name of High School/College, if applicable

During the upcoming academic year (2013-2014), I will be in the following grade:
9th
10th
11th
12th
College Freshman
College Sophomore
College Junior
College Senior
Earned GED
Obtaining GED
Dropped out of High School at age
Dropped out of College at age

Are you a pregnant or parenting teen? Yes No
If yes, at what age did you become a teen mother or father?

Do you currently have a job?
Yes, I work more than 20 hours/week
Yes, I work less than 20 hours/week
No, I don't work for pay

List any extracurricular activities or leadership positions you hold. Tell us what your favorite thing is about participating in each activity.

Do you have any writing experience beyond school work? Journalism or blogging? If so, explain and, if possible, include links to any of your work that is published online.

How often do you perform the following activities?

	Multiple times a day	Once a day	At least once a week but not every day	At least once a month but not every week	Less than once a month	Not in the last three months
Go online
Check email
Use instant messaging
Send text messages
Check Facebook
Use Twitter

How comfortable are you with discussing the following topics?

	Very	Somewhat	Not Really	Not Familiar
STDs
Condoms
Contraceptive Methods (Birth Control Pills)
AIDS/HIV

Short answer questions

Please respond to one of the three questions. Please limit your answer to no more than 250 words.

	Why is teen pregnancy prevention important to you?

	What qualities or skills do you have that would add to the Youth Leadership Team to prevent teen pregnancy?

	Why do you want to be a member of the 2013-2014 Teen Pregnancy Prevention's Youth Leadership Team?

Parental consent must be given for participation in the Mobile County Health Department’s Youth Leadership Team to prevent teen pregnancy. Please download & print the form once the application has been submitted.

All Youth Leadership Team Applicants must be sponsored by an organization or an individual. Be sure to download & print the form once the application has been submitted.

All forms must be returned by fax or mail to the Teen Pregnancy Prevention Program.


	Mobile County Health Department


	ThinkTeen.org


	Alabama Baby Coalition


	Children's Trust Fund


	Alabama Department of Public Health

The Mobile TEEN Center is supported in part by project H49MC00064 from the U.S. Department of Health and Human Services,
Health Resources and Services Administration, Maternal and Child Health Bureau (Title V, Social Security Act).

Teen Pregnancy Prevention Quiz. Flash Player 9 or above is required.