YHAI Contact Form

First Name

Last Name

Preferred Name or Chosen Name

Date of Birth

Month

/

Day

/

Year

Age

Gender Pronouns

she/her/hers
he/him/his
they/them/theirs
other

Cell Phone

ext Extension

Email

Name and Cell Phone Number of a Friend/Family Member

This person would be contacted if your phone dies.

Facebook Username

Instagram Username

8kzra5fi27ba

Snapchat Username

What is the best way to contact you?

What is the highest grade you completed in school?

Are you currently enrolled in school?

Yes
No

If yes, where and what level?

Do you have children who are currently in your care?

Yes
No

Will you require childcare to be able to participate in YHAI-related meetings?

Yes
No

Your Gifts, Talents and Interests

Tell us why you'd like to join the Youth Homeless Action Initiative.

What do you hope to gain from being a YHAI member?

Check all that apply.

Meet other young people
Learn skills I can use in the future
Advocate for improved services for youth
Other

What makes you passionate about advocating for youth who have experienced homelessness or housing instability?

Have you ever lived on the streets/in a car/in a tent/in a barn/etc?

Yes
No

Have you ever stayed at a shelter?

Yes
No

Have you ever couch surfed/been doubled up in someone else's house/apt?

Yes
No

Did you ever live on your own, without an adult to care for you, before you were 19?

Yes
No

Have you ever lacked a safe place to live?

Yes
No

Have you ever been a state ward?

Yes
No

Have you been on probation (juvenile or adult)?

Yes
No

Have you experienced a failed adoption?

Yes
No

Have you ever run away from an unsafe home?

Yes
No

Have you aged out of the child welfare system with no place to live?

Yes
No

Have you ever experienced human trafficking?

Yes
No

Have you ever been the victim of sexual exploitation?

Yes
No

Do you identify as BIPOC (Black, Indigenous or other Person of Color)?

Yes
No

Do you identify with the LGBTQIA+ community?

Yes
No

Work and Leadership History

You do not need to have any special experience to be accepted. We just want to learn more about you. Please share any work or leadership history. This includes volunteer work, school programs and social or recreational activities.

Regularly scheduled YHAI meetings?

Yes
No

Actively participating in breakout groups or being part of a committee utilizing your lived experience and lived expertise within a selected group?

Yes
No

Contact an adult ally or fellow YHAI member if you are unable to attend a meeting?

Yes
No

By typing my name in the field below, and signing this form, I agree to serving on the Youth Homeless Action Initiative Board to the best of my ability.

Date of Signature

YOUTH HOMELESS

ACTION INITIATIVE

Youth Homeless Action Initiative (YHAI) Contact Form

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