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Application for UR Office of Health Equity Research's Youth Advisory Board

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Before filling out this application, make sure to read through the FAQ to learn more about the Board and its requirements!

If you have any questions, please reach out to HEYA@urmc.rochester.edu. If you would prefer to apply by paper application, please print out this page and mail your completed application to: Office of Health Equity Research, UR Center for Community Health and Prevention, 46 Prince Street, Suite 100, Rochester, NY 14607

Thank you!

Name

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Date of Birth

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M-D-Y

Address

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Grade (in the Fall)

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School

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Phone

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How did you learn about the Board?

Name of parent/guardian

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Phone of parent/guardian

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Email of parent/guardian

My parent/guardian prefers to receive communication in a language other than English

What language does your parent/guardian prefer to communicate in?

Please let us know:

Why would you like to be a part of the Office of Health Equity Research's Youth Advisory Board?

and

What do you think that you would be able to contribute to a group like this?

You can include how any parts of your experiences, background, identity, or interests would shape your perspective and feedback as a Board member.

A response to this question is required for your application to be reviewed.

Upload your file below. If you are having trouble uploading please send an email to HEYA@urmc.rochester.edu.

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Upload file

I prefer to communicate in a language other than English (for Board meetings)

What language do you prefer to communicate in?

Do you have any accessibility needs for meetings?

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Do you need assistance traveling to meetings at the University of Rochester? We will work with anyone who needs assistance getting to meetings to make sure they can attend!

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Yes

Not sure

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We plan to provide food for Board meetings. Please let us know any food allergies, restrictions or preferences.

What is your expected availability?

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Monday Tuesday Wednesday Thursday Friday Saturday

What times work best (generally)?

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You have the option to receive messages from the Board team by email and/or text messaging for Board-related updates. If you don't want to receive emails or texts, we would communicate by phone call and/or mail.

Email and/or texts may be unencrypted (unprotected). That means they are not secure and could be shared outside of you and the Board team, including personal information. The University of Rochester is not responsible for any interception of messages sent through email or texting. You are responsible for any fees charged by your carrier's service plan for text messaging.

You can stop receiving texts or emails anytime by telling the Board team or sending a reply message that says "Stop text" or "Stop email."

Would you like to receive emails from the Board team?

Yes No

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Would you like to receive text messages from the Board team?

Yes No

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Race & Ethnicity

If you do not wish to answer, you can write that.

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Gender

If you do not wish to answer, you can write that.

* must provide value

Do you identify as a member of the LGBTQ community?

Yes

Not sure/prefer not to say

Is there anything else you would like to share? Do you have any questions?

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.