2. 
4. This application is for Roseville youths interested in volunteering with a City of Roseville Advisory Commission. In order to complete this application, you will need a valid email address. All items marked with a star (*) are required fields.
6. Contact Information
8. Date of Application (MM/DD/YYYY)*
10. First Name*
11. Last Name*
13. Address 1 (no P.O. boxes please)*
15. Address 2
17. City*
18. State*
19. Zip Code*
21. Home or Cell Phone Number*
22. Email Address*
24. Date of Birth (MM/DD/YYYY)*
25. Grade During 2021-22 School Year?*
27. I am under age 18 *

    1. Yes
    2. No. I am over age 18 but still a student in high school.

    For youth applicants under age 18, please have a parent/guardian complete the Parent/Guardian Section below)

29. City of Roseville Commissions

    The City of Roseville has citizen advisory commissions that allow Youth Commissioners. Each commission reviews specific areas of interest and provides advice to the city council.  Before filling out the application, please review the various commissions’ functions and duties. Each commission has their own webpage where you can learn more. 

31. Which Commission are you applying to?*
    -- Select One --Finance CommissionHuman Rights, Inclusion and Engagement CommissionParks and Recreation CommissionPlanning CommissionPublic Works, Environment and Transportation Commission
33. Note
    There is no character limit for the next two fields.
35. Roseville commissions are advisory to the city council. Please describe any unique qualities, talents, or experiences you have that would inform your perspective on the Commission to which you are applying.*
37. Please list school and community activities or service organizations in which you are involved:*
39. Please indicate any reasonable accommodation needed during commissioner interviews and onboarding.
41. Have you previously served on a board or commission for the City of Roseville?*

    1. No
    2. Yes
42. If yes, which list name of commission and years of service:
44. Have you served on a board or commission for another governmental entity?*

    1. No
    2. Yes
45. If yes, please list the entity and your role:
47. Voting (This section to be completed by applicant):

    Most commissions conduct a lot of their work by consensus as well as through dialogue and collaboration. However, there will be instances where votes are taken on items of interest. Youth Commissioners must choose whether they wish to be considered a voting member or a non-voting member of the commission when they apply. 

49. I wish to serve as a voting member*

    1. Yes
    2. No
51. If you choose to be a voting member there are responsibilities that you must acknowledge and agree to abide by. They include the following:*

    By checking each box you acknowledge and agree to abide by them. 

    1. I agree to attend all trainings offered by the staff liaison and city as it relates to my role as a commissioner
    2. I understand that I will be issued a City of Roseville email address, which I will only use to conduct commission-related business. This city-issued email address is public.
    3. I understand that a commission’s formal recommendations to the City Council may become part of legal disputes.
    4. I understand that I am expected to abide by the city’s ethics code and therefore subject to the complaint process of the city’s ethics code.
55. Parent/Guardian*

    Youth applicants less than 18 years of age are required to receive parental permission in order to serve on a City of Roseville commission. The following should be completed by a parent/legal guardian. 

    Please acknowledge by checking each box. 

    1. I am the parent or legal guardian of the applicant listed above.
    2. I have reviewed this application and understand that participation on a Roseville commission is voluntary.
    3. I understand commission meetings are broadcast live and the applicant's image will be used on tv in relation to their work on the commission.
    4. I understand certain data on youth as an applicant and member of a commission is considered pubic under MN law and therefore available upon request.
57. Parent/Guardian Acknowledgment - Application Data*

    I understand that if the youth’s application is selected for consideration by the City Council, all of the data contained in their application materials and provided to the City in support of their application will be published in the City Council packet and will be made available to the public, with the exception of address, email address, and phone number. I give permission for this disclosure.

    1. I agree
59. Parent/Guardian Permission to Serve*

    As parent/legal guardian, I give permission for the youth applicant to serve on a City of Roseville commission.

    1. Yes
    2. No
61. Parent/Guardian Permission to Vote*

    As parent/legal guardian, I give my permission for the youth applicant to serve as a voting member of a City of Roseville Commission.

    1. Yes
    2. No
63. Parental/Guardian Image Permission*

    As parent/legal guardian, I give my permission for the youth applicant’s image to be used and disclosed to the public in photographs, videos, websites and/or social media.

    1. Yes
    2. No
67. Demographics

    The City of Roseville seeks to increase diversity on volunteer commissions; diversity in terms of: racial, economic, age, gender, geographic, sexual orientation, ownership, disability and education attainment. Your answers on this form help us determine the success of our efforts and are not used in determining appointments to boards and commissions. Your information is kept strictly confidential and when reported, will not identify any individual.

69. How do you identify your gender?*
    -- Select One --FemaleMaleTransgenderNon-binaryOtherChoose not to self-identify
71. Do you have a sensory, physical or mental disability?*
    -- Select One --YesNoChoose not to self-identify
73. If yes, into which category does your disability fall? (Choose all that apply)*

    1. Mobility
    2. Sight
    3. Hearing
    4. Speech
    5. Developmental
    6. Other
    7. Choose not to self-identify
75. If "Other" please describe:
77. How did you hear about this opportunity?*
    -- Select One --City websiteTeacher or CounselorOther (at school)Social MediaFriendParentOtherChoose not to self-identify
79. If "Other" please list:
81. What is your race/ethnicity? (Check all that apply)*

    1. American Indian/Alaska Native
    2. Asian
    3. Black/African American
    4. Hispanic or Latino origin
    5. Native Hawaiian or other Pacific Islander
    6. White/Caucasian
    7. Other race/ethncity
    8. Choose not to self-identify
83. What tribe are you affiliated with?*
    -- Select One --Bois ForteFond du LacGrand PortageLeech LakeLower SouixMille LacsPrairie IslandRed LakeShakopeeUpper SouixWhite EarthOtherChoose not to self-identify
85. If "Other" please describe:
87. If you selected "Asian", please choose:*
    -- Select One --HmongCambodianVietnameseKarenAsian IndianBangladeshiChineseFilipinoIndonesianJapaneseKoreanLaoMalaysianPakistaniSri LankenTaiwaneseThaiBurmeseOtherChoose not to self-identify
89. If you selected "Black/African American", please choose:*
    -- Select One --African AmericanSomaliOromoEthiopianNigerianLiberianKenyanSudaneseOther West AfricanOther East AfricanOther North AfricanChoose not to self-identify
91. If "Other", please describe:
93. Please specify country of origin:
95. If "Other", please specify:
97. Signature of Guardian/Parent*

    Please type your name (this will serve as your digital signature)

98. Date (MM/DD/YYYY)*
100. Contact information for Parent/Guardian

     Please provide the best method to contact you, the parent/guardian, should the need arise. (Email, phone)

102. Signature of Applicant*
     Please type your name (this will serve as your digital signature). By typing my name, I agree that I wish to be considered for appointment to a City Commission.
103. Date (MM/DD/YYYY)*
Leave This Blank:


105. 1. Receive an email copy of this form.
106. Email address

     This field is not part of the form submission.

107. Submit Submit and Print

* indicates a required field