chicago youth Center Rebecca K. Crown 
LOCAL Advisory Board Membership Application	
Applicant Information
	
Name:	Email:	Phone:	
Current address:	
City:	State:	ZIP Code:	
Employment Information	
Current employer:	
Does your employer match funds?
	Please circle         yes     no 	
Retired	Please circle          yes     no 	
Emergency Contact	
Name 	
Relationship 	Phone:	
	
membership and Associations (professional, Board, SOCIAL, religious, honorary, etc)	
Name:	
Name:                              	
References	
Name:                                                                        Address:	Phone:	
1)			
2)			
3)			
                                             Areas of Interest (mark your areas of interest)	
Fundraising 	Programs           	Mentoring  ()	
Finance                       	Community Engagement       	Volunteer ()	
Membership                	Member Engagement   ()	Other  ()	
Children Enrolled in CYC Programs (if any)	
Name                                                       Age	Name                                                          Age	
Name                                                       Age	Name                                                          Age	
	
Please submit a your application,  
Attention: Roberta Douglas, roberta.douglas@chicagoyouthceners.org
CYC-Rebecca K Crown Center 7601 S. Phillips 60649 773.731.0444 Fax#773.731.4177	
Signature of applicant:
	Date:

Narrative

Please take a moment to tell us briefly about yourself and what unique talents you can bring to the Chicago Youth Centers-Rebecca K. Crown