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Application Part II Page 1 of 5
City of Elk Grove Application for Appointment
Elk Grove Youth Commission
INSTRUCTIONS: Provide all information requested; use ink; any attachments must be single sided on 8.5 x 11 paper. If you will be representing an organization, you must include a letter from the organization recommending you as their representative. IMPORTANT: Any letter(s) of recommendation(s) must be made a part of this application and submitted together. Any letters supporting your application will not be accepted if it is received after your application is filed with the Office of the City Clerk. For further information please call Carrie Monti at (916) 478-2202, [email protected]. Note: All information provided on this form is public record. Answer all questions and return completed application on or before the DEADLINE of July 15, 2020 at 5:00 p.m. to: Office of the City Clerk, 8401 Laguna Palms Way, Elk Grove, CA 95758 Applicant Name: _______________________________________________________ Date of birth: __________________________________________________________ Home Address: ________________________________________________________ Street City Zip Code Mailing Address (If different than home address): Telephone Number: ____________________________________________________ Email Address: ________________________________________________________ *City Council District in which you reside:__________________________________ *Note: See page 5 of application for Council District Map; also available online at: http://www.elkgrovecity.org/city_hall/city_government/city_council/council_district_map
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Name and address of school you attend: _____________________________________________________________________ _____________________________________________________________________ Are you an immediate family member of a City Council Member? (Please Circle) Yes No Members are required to attend meetings at least one time per month. If appointed, will you be able to attend meetings regularly and devote the time necessary to fulfill your duties as a member? (Please Circle) Yes No Background Information: (NOTE: You may attach a resume to your application.) Have you ever served on an advisory group? (Please Circle) Yes No Please list experience, community activities or other qualifications that would be helpful to the City Council in evaluating your application: _____________________________________________________________________ _____________________________________________________________________ ____________________________________________________________________ Please state the reasons you would like to be a member of this commission:
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What do you feel are the issues most greatly affecting youth in your area? _____________________________________________________________________ _____________________________________________________________________ What youth related improvements do you recommend? _____________________________________________________________________ _____________________________________________________________________
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I DECLARE, UNDER PENALTY OF DISQUALIFICATION AND TERMINATION, THAT ALL STATEMENTS IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE: ____________________________________ _________________ Student Signature Date ____________________________________ _________________ Signature of parent or guardian Date Please identify any specialized accommodations you will need for equal participation (e.g. hearing or sight impaired): Please check ONE box only for the predominant (70%) racial/ethnic category with which you most closely identify with: ___ White (Non Hispanic or Latino) – All persons having origins in any of the original
peoples of Europe, North Africa or the Middle East.
___ Black or African American (Non Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.
___ Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
___ Asian (Non Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
___ Native Hawaiian or Other Pacific Islander (Non Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
___ American Indian or Alaska Native (Non Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Tribal Affiliation ___________________________________________________
___ Two or More Races (Non Hispanic or Latino) - Persons who identify with two or more racial categories named above.
___ Decline to answer Gender: Male ____ Female ____
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Union Pacific
Elk GroveRegional
ParkBartholomewSports Park
Underwood
MorseCommunity
Wright Phase 2
Civic Center
Reardan
Civic Center
LagunaCommunity Camden Park
Greenbelt
Nottoli
Johnson
Kloss
Oasis
Rau
KammererFamily Park
Betschart
Derr-Okamoto
Backer
LichtenbergerSouth
Bartholomew
MachadoDairy
Hill
Wackman
Tuscan
Zehnder
ArcadianVillage
Luttig
Horseshoe
Amundson
CrookedCreek
Lawrence
Kunsting
Simpson
Strong
TreasureHomes
Mcconnell
StephensonFamily
Town Square
Jungkeit
Entrican
Miwok
Pinkerton
Baker
PedersonKing
Singh/Kaur
Zimbelman
George
Foulks
Hawkins
Fite
Houde
Feickert
Guttridge
Womack
Fales
Promenade
Beeman
Green Belt
Johnston Island
Constellation
Mix
McgearyRanch
Colton
Lewis
Gates
Castello
ArborBuscher
Keema
Henderson
Miles
Lombardi
Fleming
Caterino
Berens
Herburger
Batey
JordanFamily
Smedberg
Perez
PerrySheldon
Place
Oneto
Bradford
Karamanos
Mendoza
Schauer
Rose
Gage
Van Doren
MacdonaldPhase 2
Rose Garden
Russell
Fite
Camden
Hop RanchFallbrook
LagunaRiviera
Quail RanchEstates
LagunaSprings
Sheldon
GreaterSheldon Road
Estates
Egcc
Lakeside
Stonelake
WatermanMeadowsLaguna Lake
Van RuitenRanch
LagunaEstates
HeritageLakeside
PoplarHollow
Big Horn
Retreat atValley Hi
Coventry
95758
95624
95830
95828
95823
95829
Ba der
Bond
Waterm
a n
Whitelock
Elk Grove
Sheldon
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4
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National Demographics Corporation, October 16, 2019
Map layersCurrentHOACensus BlockCensus Block GroupCensus TractLandmark AreaWater Area5-Digit ZIP CodePipeline/Power LineRailroadRiverStreets_cityLandmark PointNeighborhood AssocParksSE_Study_Area
City Council Members shall be elected by-district in City Council Districts 1 and 3 beginning at the November 3, 2020 General Municipal Election, and every four years
thereafter, as such City Council Districts may be amended from time to time. City Council Members shall be elected by-district in City Council Districts 2 and 4
beginning at the November 8, 2022 General Municipal Election, and every four years thereafter, as such City Council Districts may be amended from time to time. The
office of the directly elected mayor shall be elected "at-large" at the November 3, 2020 General Municipal Election, and every two years thereafter.