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, cmonti@elkgrovecity.org. 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

Application Part II Page 2 of 5

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

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Bond

Waterm

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Whitelock

Elk Grove

Sheldon

1

3

4

2

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.