Youth Leadership Application
Content
Get Involved with Youth Leadership in New York
Please fill out the following contact information. The information you provide is confidential. The information will only be viewed by AIM Youth Leadership staff. If you choose to be placed on the New York State Department of Education distribution list, only your email will be shared.
Contact Information
Name: Street Address: Cite/State/Zip: Phone: Email:
Additional Information
How old are you? What county do you live in? Would you prefer to be contact by phone, email, mail, or another method? Would you like future information sent in an Alternative format? If "yes" please tell us what Alternate Format you would like (i.e. Braille, Large Print, Etc.).
Would you like to be placed on a New York State Department of Education distribution list to receive information and updates related to youth with disabilities? Yes No What kind of disability do you have? Check all that apply. This question is optional. It helps us to know more about the demographics of interested youth. Mobility Hearing
Visual Learning Emotional/Behavioral Cognitive
Health Other (please list)
Interests
Which Youth Leadership activities are you interested in? Please check all of the activities you are interested in.
(For more detailed information on these opportunities check out our web page. www.aimcil.com/aimyouth)
Attend the NYAIL Conference Planning Committee--Youth Track NYAIL Conference NYSILC Youth Advisory Committee (YAC) Get involved with your local Independent Living Center
Thanks for your interest in Youth Leadership in New York!
Mail to: AIM 271 E.First St. Corning NY 14830 Attn. Renée Fax: 607-937-5125 Email: [email protected]
Renée Blank and Chris Shoemaker AIM Independent Living Center 271 East First Street Corning, NY 14830
Please fill out the following contact information. The information you provide is confidential. The information will only be viewed by AIM Youth Leadership staff. If you choose to be placed on the New York State Department of Education distribution list, only your email will be shared.
Contact Information
Name: Street Address: Cite/State/Zip: Phone: Email:
Additional Information
How old are you? What county do you live in? Would you prefer to be contact by phone, email, mail, or another method? Would you like future information sent in an Alternative format? If "yes" please tell us what Alternate Format you would like (i.e. Braille, Large Print, Etc.).
Would you like to be placed on a New York State Department of Education distribution list to receive information and updates related to youth with disabilities? Yes No What kind of disability do you have? Check all that apply. This question is optional. It helps us to know more about the demographics of interested youth. Mobility Hearing
Visual Learning Emotional/Behavioral Cognitive
Health Other (please list)
Interests
Which Youth Leadership activities are you interested in? Please check all of the activities you are interested in.
(For more detailed information on these opportunities check out our web page. www.aimcil.com/aimyouth)
Attend the NYAIL Conference Planning Committee--Youth Track NYAIL Conference NYSILC Youth Advisory Committee (YAC) Get involved with your local Independent Living Center
Thanks for your interest in Youth Leadership in New York!
Mail to: AIM 271 E.First St. Corning NY 14830 Attn. Renée Fax: 607-937-5125 Email: [email protected]
Renée Blank and Chris Shoemaker AIM Independent Living Center 271 East First Street Corning, NY 14830
