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Prime Time Palm Beach County

Youth Advisory Council

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Prime Time Palm Beach County's Youth Empowerment Initiative is where youth voice and interests lead to real action. By participating, youth will connect with other teens, build leadership skills, and create youth-led projects. Youth will work alongside supportive adult allies to make a positive impact in the community, and they will have the opportunity to earn community service hours and additional compensation for their efforts along the way.

Contact: Legal Parent/Guardian Information

First Name

Last Name

Email Address

Mobile Phone

Address Line 1

Address Line 2

City

State

Zip Code

I am the parent or legal guardian of the above-named child and give permission for them to participate in Prime Time Palm Beach County's Youth Advisory Council (YAC)

Please send me a copy of the consent form in my preferred language.

My preferred language is:

Is there an additional Parent/Guardian you would like to add to this application? (They do not need to reside in the household)

Contact: Legal Parent/Guardian Information

First Name

Last Name

Email Address

Mobile Phone

Do they reside in the same household?

Address Line 1

Address Line 2

City

State

Zip Code

Youth Information

First Name

Last Name

Email Address

Mobile Phone

Ethnicity

Gender

Date of Birth

Shirt Size (Adult Unisex)

Current Grade Level

Current School

Afterschool Program (if any)

County of Residence

If there is additional youth in grades 6th through 12th who are interested in participating, please add them by clicking on the blue link indicating "Add another youth in 6th grade or above".

Waiver, Release, and Media Consent

Disclaimer: I hereby grant permission to Prime Time Palm Beach County, Inc, to use my child’s/afterschool participant’s photograph on its website, posters, exhibits or in other printed or electronic publication (video, CD, newsletters, brochures, etc.) without further consideration and I acknowledge Prime Time’s right to crop or treat the photograph at its discretion. I also acknowledge that Prime Time may choose not to use these photos at this time, but may do so at its own discretion at a later date. I also hereby waive the right to inspect or approve the photographs or electronic matter that may be used in conjunction with them now or in the future, whether intended use is known or unknown to me. I waive any right to royalties or other compensation arising from or related to the use of the photographs. I also understand that once an image is published or posted on Prime Time’s website, the image can be downloaded by any computer with access to the Internet. I understand that Prime Time cannot control unauthorized use of these photos and videos. Therefore, I hereby agree to release and hold harmless the Prime Time staff, volunteers, contractors or aides, on behalf of Prime Time from and against any claims, damages, or liability arising from or related to the use of the photographs or videos, including but not limited to any reuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in association of the finished product. Prime Time reserves the right to discontinue use of photos without notice.

By signing below, I acknowledge that my participation in this beach well-being activity is voluntary and involves inherent risks, including exposure to sun, heat, uneven sand terrain, and water-related hazards. I knowingly and voluntarily assume all such risks and hereby release and hold harmless Prime Time Palm Beach County, its staff, and volunteers from any and all claims or liabilities for personal injury, property damage, or loss arising from my participation, except in cases of gross negligence. I certify that I am in good physical health and authorized to participate.

Additionally, I hereby now and forever release, acquit, waive, discharge and covenant not to sue Prime Time Palm Beach County from any and all claims, demands, causes of action, damages, losses, or expenses arising out of or related to my participation in activity.

Furthermore, I grant Prime Time Palm Beach County the irrevocable right to use my name, voice, likeness, or images captured during this event in any media for promotional or marketing purposes in 2026 and beyond without further compensation unless I opt out.

Please ensure to sign form on the next page.

Review completed form and signature line will be at the bottom of the page.

Contact Information