LifeAct Youth Advisory Board Application
LifeAct YAB members and volunteers are vital to LifeAct's success.  If you choose to participate as a YAB member with LifeAct, you will help reduce the stigma about mental illness, prevent teen suicide, help young people enjoy healthy, productive lives and support survivors of suicide
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Email *
Full Name (first and last) *
High School *
Graduation Year *
Date of Birth *
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Gender Identity
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What pronouns do you use? *
Street Address
City
State
Zip Code
Home Phone
Cell Phone *
Are you a survivor of suicide loss *
Person Lost to Suicide
Relationship
Date of Loss
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DD
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Where are you in your healing journey?
Why do you wish to serve as a YAB member? *
What skill sets will you bring to LifeAct? *
Do you belong to other organizations or school Clubs? *
If Yes, please list the organization(s)
Other relevant experience or comments
There are many opportunities for our YAB members to obtain volunteer hours and get involved.  Please select those that best suit you. *
Required
How did you hear about LifeAct? *
Electronic Signature
Today's Date
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