SSHBEA Youth Council 2007 Application  

Youth Name:  

 

Your age:

 

Street Address:

 

City / State / Zip:

 

Home Phone #:

 

Parent / Guardian Name:

 

Parent / Guardian Address:

 

Parent / Guardian Name:

 

Parent / Guardian Address:

 

 

Birth Date:

 

Youth Member Email:

 

Parent Email:

 

Child Cell #:

 

Is this a verizon number?   

 

Are you going to work for points during 2007?

 

What prizes are you interested in?

 

 Membership Fee is $5.00

Give Application to YC Sponsor or mail to SSHBEA P.O.Box 1046, Shelbyville TN 37162