Your Home Phone Number
Your Cell Phone Number
Date of Birth (example: 2013-04-08)
Best way to reach you
Home PhoneCell PhoneEmail
Parent/Guardian Home Phone Number
Parent/Guardian Cell Phone Number
A lot of communication is done via phone and/or e-mail. If your child is accepted, please let us know if any contact information changes
School Contact Person/Counselor
School Contact Person/Counselor Email
Name of Hometown Newspaper
I found out about ADAPT through:
school counselor/teacher/etc.ADAPT Youth LeaderADAPT Adult Coalition MemberOther:
Name of Person Referring/Endorsing you and Relationship:
Are you available for summer meetings?
Optional Information: ADAPT does not discriminate based on race, ethnicity, sex, creed, national origin or disability. This information is not required. It is requested to facilitate our goal of assembling a diverse team.
American IndianAsianAfrican AmericanHispanicWhiteOther:
Please let us know the organizations or activities you are involved in, both in your school and/or community. These should be in order of importance, listing up to five; school, social, athletic, religious, community service, scouting or other activities and organizations in which you have participated during the last two years. If you have held a leadership position in that group- please specify what kind.
List any accomplishments, awards, honors or recognitions for academic, school, religious or community activities you have achieved or received in the last two years.
List any community service or volunteer work experience and briefly tell what was involved.
Why are you applying for ADAPT’s Youth Leadership Team?
© 2012 ADAPT - Alcohol and Drug Abuse Prevention Team, funded by DMHAS, is managed by FAMILYConnections, a nonprofit 501(c)(3) community-based counseling and family service agency with over 35 specialized programs for all ages from infants to seniors. Licensed by New Jersey’s Division of Mental Health and Addiction Services and Department of Children and Families, we deliver research-based therapeutic services in our offices and on-site in preschools, schools, and directly in the home.