APPLICATION
Childhood Obesity Prevention Advisory Group
Updated 01/20/2021
PLEASE CHECK ONE THAT APPLIES:
□ NEW APPLICATION □ RENEWAL APPLICATION
CONTACT INFORMATION
NAME: ______________________________________________________________________ ADDRESS: ______________________________________CITY/ZIP: ____________________ TELEPHONE NUMBER: ___________________EMAIL ADDRESS: _____________________
GROUP INFORMATION: WHAT SECTOR DO YOU REPRESENT? (Choose one) □ YOUTH/YOUNG ADULT (16-25) □ COMMUNITY MEMBER/GENERAL PUBLIC □ HEALTH CONTENT EXPERT / PROFESSIONAL
AFFLIATION: COMPLETE ALL RELEVANT SECTIONS
EMPLOYED BY______________________________________LENGTH OF TIME __________ POSITION ______________________GEOGRAPHIC AREA SERVED __________________ RELEVANT EXPERIENCE, IF ANY _______________________________________________
IF STUDENT, CURRENT SCHOOL/YEAR ________________________________________ RELEVANT COURSE OF STUDY, IF ANY________________________________________
IF PARENT/CAREGIVER, SCHOOL/GRADE OF CURRENT SAN PABLO STUDENT __________________________________________________________________________
LIST ANY POTENTIAL CONFLICT OF INTEREST (i.e. memberships or affiliations in groups):
____________________________________________________________________________
APPLICANT’S SIGNATURE: ___________________________ DATE: ________________ PLEASE EMAIL THE COMPLETED APPLICATION TO:
City of San Pablo, 1000 Gateway Avenue, San Pablo, CA 94806 THANK YOU FOR YOUR INTEREST. IF YOU HAVE ANY QUESTIONS PLEASE CALL: (510) 215-3000