California Department of Public Health, California Tobacco Control Program, Funded under contract No

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1 California Department of Public Health, California Tobacco Control Program, Funded under contract No

2 Who is the ACTION Youth Advisory Board? The ACTION Youth Advisory Board (ACTION YAB) is the countywide youth coalition that forms part of the countywide program the Merced Tobacco Control Program a program of the statewide non-profit organization the California Health Collaborative. ACTION YAB provides youth with the opportunity to be involved in their community. It gives youth in Merced County a platform to reach out to the community and voice their opinions about the harmful effects of tobacco products. How YOU Can Take ACTION Have you ever been out in public and smelled a cigarette? It stinks right?! Wish you could do something about it? Well now you can, the ACTION Youth Advisory Board strives to reduce the tobacco use among youth in the county of Merced. We accomplish this by participating in several activities such as park cleanups, where we find an abundance of tobacco litter, including cigarette butts that are toxic to the environment. There are also opportunities to participate in data collection activities, photo voice projects, media campaigns, and educating elected officials in local communities of the impacts of tobacco to create positive changes for our neighborhoods! Mission Possible Our mission as the ACTION Youth Advisory Board is to educate youth and the community of Merced County about the harmful effects of tobacco while creating changes in local policies/ordinances that will result in healthier and cleaner environment Member Qualifications Members must be from age (high school) Members must be residents of Merced County (with intentions of staff traveling within county limits) Members must be passionate about wanting to make a difference in their community Members must obtain a good academic standing Member Responsibilities Experience working with a nonprofit organization (California Health Collaborative) Development of leadership and advocacy skills Sharpen public speaking and communication skills Increase knowledge of tobacco and emerging product issues and share with community Network with other teens from around the Central Valley Present at city council, parks & recreation, and community meetings Work with local, county, and state elected officials 1

3 What would my commitment be? Attend and participate in ACTION Youth Advisory Board meetings Help plan countywide activities and campaigns Stay in communication with Merced County Tobacco Control Program staff via , phone, web or social media Meeting Schedule Meet at least 10 times in person or via conference call annually for minute meetings Participate in at least 2-3 community events per year to educate the community on tobacco related issues and raise awareness about tobacco policy efforts taking place in your county Meetings will take place on a weekly/biweekly basis*. A day will be set depending on group s availability Multiple meetings during the same week may occur only when needed and agreed upon in preparation for activities Meeting locations: o Merced California Health Collaborative G Street o Los Banos TBD o Atwater TBD The California Health Collaborative has two regional programs also working with youth coalitions on tobacco control in Dos Palos and Livingston. For more information or to join their youth coalition please contact (209) Unidos Por Salud Project Dos Palos 2. API PACT Project - Livingston Attendance Every member of the ACTION Youth Advisory Board is expected to be at every meeting. There will be opportunities for youth to attend additional activities which include community outreach events, educational presentations, data collection, trainings, summer camps and many more! Member must notify Youth Coordinator of absence due to illness, family emergency, important appointment, or any other reasoning why a member will be absent at least two hour prior to scheduled meeting/activity to make appropriate arrangements. Parents Understanding Every YAB member will be under the age of 18; parents/guardians must review and sign the membership recruitment packet upon return. Any activities/trips we participate in will require parents permission. All permission slips should be returned in a timely manner, if not it way result in not being able to participate in the activity. 2

4 THE REWARDS ARE ENDLESS! By joining ACTION YAB your powers will strengthen and your efforts will be rewarded Make friends all over the county & state Become a leader for tobacco control campaigns Gain great Communication and advocacy skills Gain skills for college applications & resumes Travel and represent your city Earn community service hours & recognitions All activities and trainings are FREE to you! 3

5 The Merced County Tobacco Control Program (MCTCP) is located at the statewide non-profit organization California Health Collaborative. MCTCP is a countywide tobacco control program tasked with promoting awareness of tobacco-related issues, combating illegal youth use and access to tobacco products, reducing exposure secondhand smoke and educating the community on the benefits of becoming tobacco-free! MCTCP is the local lead agency in Merced County and receives its funding from the California Department of Public Health - California Tobacco Control Program Patrik White - Youth Coordinator Pwhite@healthcollaborative.org Stephanie Gonzalez - Program Coordinator Sgonzalez@healthcollaborative.org Vicky Vega - Community Engagement Coordinator Vvega@healthcollaborative.org CALL OUR OFFICE AT: (209) Please complete pages 5-9 of the application and submit for review to Patrik White. Please contact him at (209) to find the best option to submit. You should hear a response within two weeks of submitting application! 4

6 Youth Application & Emergency Contact Form YOUTH PARTICIPANT INFORMATION Name: First Name Last Name Address: Number and Street City and Zip Phone: Youth Cell Phone Home Phone Youth Program Site: Date of Birth: Age: Gender: Male Female Are you a student? Yes No Name of School: Grade: Freshman Sophomore Junior Senior T-shirt size: PARENT AND EMERGENCY CONTACT INFORMATION Parent /Guardian Name: Phone: Home Phone Cell Phone (1) Emergency Contact Name: Relationship: Emergency Contact Phone: Home Phone Work, and/or Cell Phone (2) Emergency Contact Name: Relationship: Emergency Contact Phone: Home Phone Work, and/or Cell Phone Medical information: (Please list any allergies to drugs, foods, insect bites, Etc.) 5

7 Youth Availability Please list your availability for days/time during school year and summer: Select the times you are best available SCHOOL YEAR Morning (8-12pm) Afternoon (12-3pm) Evenings (3-8pm) Monday Tuesday Wednesday Thursday Friday Saturday SUMMER Morning (8-12pm) Afternoon (12-3pm) Evenings (3-8pm) Monday Tuesday Wednesday Thursday Friday Saturday Please list any other activities you participate during the school year (i.e. sports/clubs): 6

8 Youth Recruitment Questionnaire Please answer the following questions to your best ability 1. What are your thoughts about tobacco products: cigarettes, chew, cigars, including vapes & e- cigarettes? 2. Have you participated in any other tobacco prevention and/or youth programs? What was your experience? 3. What experience have you had that empowered you to want to create a change toward tobacco? Have you ever had an experience (personal, family, community) that shaped that decision? 4. What impacts have you made or plan on making in the future to improve your community? 5. Why would you be a good candidate for the program? What skills and qualities would you be able to provide as a member of the ACTION Youth Advisory Board? 7

9 ACTION Youth Advisory Board Member Agreement Parent/Guardian Agreement This agreement is so that parents and members will understand what standards are acceptable and what is to be expected when being part of ACTION YAB. Meetings Attendance is very important for members of the ACTION YAB. Participation in regular meetings and additional activities will provide the best experience for youth! If a member in unable to go to a meeting or a community activity, youth member must notify Youth Coordinator with at least a two hour notice, unless it was an unforeseen reason. Failure to notify anyone will result in an unexcused absence, which can result in removal of ACTION YAB if the behavior becomes common. Parent/Guardian Agreement I,, have reviewed the membership recruitment packet with my child for the ACTION Youth Advisory Board and understand what my responsibilities as the guardian of the child applying are. I agree that my child can participate in the program and represent ACTION YAB. I also agree with the terms and condition and know this program will may sometimes be time consuming for my child. Parent/Guardian Signature: Date: Parent/Guardian Contact info: Cell # Work # Youth Agreement I,, am aware of the duties and qualifications it requires to be part of ACTION YAB. I understand my responsibility as an ACTION YAB member and I accept them. I will represent the program to my greatest ability. I will attend every meeting and activity that I am required to go to unless otherwise told so, or in case of an emergency. Youth Applicant Signature: Date: Youth Applicant Contact Cell # High School Name: Graduate Year: 8

10 Media & Participation Release Form CONSENT TO PHOTOGRAPH, AUDIO, OR VIDEOTAPE A STUDENT FOR NON-PROFIT USE (e.g. Educational, public service, or health awareness purposes) Youth Participant Name: On behalf of the youth participant named above, I grant permission to the California Health Collaborative (CHC), Merced County Tobacco Control Program (MCTCP) ACTION Youth Advisory Board and members of the media to use/take photographs, video and/or audio recordings, interviews, quotes, name and/or other rendering for use in the CHC s publications, including web sites, social sites, promotional items, lectures, and presentations by the CHC or other electronic forms or media without notifying me. I hereby waive any right to inspect or approve the photographs, publications, or electronic matter that may be used in conjunction with them now or in the future, whether that use is known or unknown to me, and I waive my rights to any benefits arising from, or related to, the use of the images. I also grant to the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release the California Health Collaborative, the Merced County Tobacco Control Program, and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above. I recognize that the Youth s participation in the Programs is a privilege and, as consideration for this privilege, I release the California Health Collaborative, MCTCP, including its employees, agents, members, directors and trustees from responsibility and liability for the Youth. This release does not apply to any injury caused by a negligent act on the part of MCTCP employees or volunteers. The medical information I have provided on the Contact Information form is correct to the best of my knowledge. I authorize CHC to call 911 or seek other emergency services on behalf of the Youth. I understand that both MCTCP and California Health Collaborative nor its insurance carrier is liable for any medical or hospital costs incurred by any Youth and, therefore, I agree to remain fully liable and responsible for the payment of any such costs. This consent and release is binding on my successors and assigns, and it is continuous and may not be revoked. I hereby certify that I have read or it has been explained to me the meaning of this document, that I am at least 18 years of age, or the parent/guardian of the minor named below and have signed this authorization. Parent/Guardian Name: (please print): Parent/Guardian Signature: Date: Youth Participant Signature: 9