Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

The student board will require bi-monthly meetings that meet at the HUB building in Mason City. Additionally, board members will be needed to help work on the facility. Are you willing to commit to these requirements? *

Yes

No

Do you have the permission of your parents/guardians to be a part of the student center board? *

Yes

No

All student board members are required to maintain a 2.0 GPA or higher. Do you meet this requirement? *

Yes

No

Student center board members are expected to be a positive influence within the Illini Central school district and community. Therefore, all board members MUST refrain from the consumption of alcohol, smoking, drug use, or other illegal activities. Do you commit to refrain from participating in these activities? *

Yes

No

Date

MM

DD

YYYY

Name

First Name

Last Name