Fifth District Youth Advisory Council – Application

The Fifth District Youth Advisory Council consists of twenty-five youth, ages 14-19 who live, work, or go to school in Ventura County’s Fifth Supervisorial District. The Youth Advisory Council advises Supervisor Vianey Lopez on local issues and offers an opportunity for youth to get involved locally.

To be considered for the 2025-26 Youth Advisory Council, the following three sections of the application packet below must be submitted (or a PDF application packet emailed). Please note that a parent or guardian must complete sections II and III if you are under 18:

I. Application
II. 2025-2026 Parent or Guardian Consent and Waiver Claims Form
III. 2025-2026 Photographic and Video Release and Consent Form

Application packets must be submitted by Wednesday September 24, 2025 at 11:59 pm pacific time.

Completed PDF application packets may be emailed with the subject line: “First Name Last Name – Youth Council Application Packet.”

If you have questions about the Youth Advisory Council or this application, you may contact Supervisor.Lopez@venturacounty.gov or call (805) 654-2613.

FIFTH DISTRICT YOUTH ADVISOR COUNCIL - APPLICATION PACKET

Download Printable Application Packet (PDF version)

I. Application

All required fields must be filled in.

Name(Required)

First Last

Pronouns

Age

Please enter a number from 0 to 20.

Email(Required)

Phone

Address

Street Address City State Zip

1a. Do you live, work, or attend school in the Fifth Supervisorial District?

(You may use the Find My District Tool to verify that your home, school, or work address is located in the Fifth District.)

Yes

1b. If ‘yes’, check all that apply:

Live

Work

Attend School

2a. Please select your most recent or current educational experience:

High School

GED Program

Certificate Program (online or in-person)

College or University

Military

Trade School

Other

If other, please describe your most recent or current educational experience:

2b. If ‘high school’ or ‘college’, what grade level are you currently:

Freshman

Sophomore

Junior

Senior

Other

If other, please describe what grade level are you currently:

3. Of the policy and governance issues listed below, which three are of most interest to you?

Education

Housing

Homelessness

Environment

Public Safety

Healthcare

Mental Health

Transportation

Agriculture

Other

If other, please describe the policy and governance issue you are intereseted in:

4. Why would you like to become a Youth Advisory Council member and/or what would you hope to get out of this experience?

5. What are one or two things that are of most concern to you or to other youth in your community?

6. What do you like to do for fun?

7. This position will be an appointment by Supervisor Vianey Lopez, and you will be serving the Supervisor’s office in an official capacity at the discretion of the Supervisor. This is a voluntary position, and no compensation is included. Please acknowledge below that you both understand and agree to this statement.(Required)

I understand and agree to the above statement.

I do not understand and/or agree to the above statement.

II. 2025 – 2026 Parent or Guardian Consent and Waiver Claims Form

All required fields must be filled in.

Acknowledgement(Required)

I acknowledge that this form has been completed by a parent or guardian.

I hereby authorize my child,(Required)

Full name of child

to participate in the Fifth District Youth Advisory Council program activities. My child is currently in good physical and medical condition. In the event that my child becomes ill or injured, he or she may receive First Aid.

In case of emergency, my child may be admitted to a hospital. I agree to hold harmless the County of Ventura, its officers, agents, and employees for medical aid rendered. I will also reimburse the County of Ventura for medical or other expenses incurred for medical aid on behalf of my child.

I understand and acknowledge that the County of Ventura does not provide medical insurance for the Fifth District Youth Advisory Council activity participants. I hereby release the County of Ventura, its officers, agents, and employees from all liability, demands or claims from any loss, damage or injury resulting from participation in the Fifth District Youth Advisory Council, and do hereby give consent for my child to receive emergency treatment.

Name of Parent or Guardian(Required)

Full Name

Date(Required)

MM slash DD slash YYYY

Address(Required)

Street Address City State Zip

Cell Phone(Required)

Work Phone

Child's Medical Information

Child's Full Name(Required)

Full Name

Doctor(Required)

Doctor Name

Phone(Required)

Existing Medical Conditions(Required)

Allergies(Required)

Special needs(Required)

III. 2025 – 2026 Photographic and Video Release and Consent Form

All required fields must be filled in.

Acknowledgement(Required)

I acknowledge that this form has been completed by a parent or guardian.

I hereby, freely and voluntarily, give my consent to The County of Ventura to use mine (or my child’s image) and/or likeness in any photographs, videos, audio recordings, or other media content produced by or on behalf of The County of Ventura (the "Content").

I understand that the Content may be used for any lawful purpose, including but not limited to marketing, advertising, promotion, and social media. I also understand that the Content may be published, distributed, and exhibited in various forms and media, including but not limited to print, broadcast, digital, and on the County’s websites.

I hereby waive any right to inspect or approve the Content before its use. I release and discharge The County of Ventura, its officers, employees, agents, and assigns, from any and all claims, damages, and liabilities arising out of or in connection with the use of the Content, including without limitation, any and all claims for libel and/or invasion of privacy. I understand that this release cannot be revoked.

I represent and warrant that I am at least 18 years of age. I have read and fully understand the contents of this release.

If the individual is under 18 years of age:

I hereby consent to the use of my child's image and/or likeness in the Content described above, and I agree to the terms of this consent form on behalf of my child. I represent and warrant that I am the parent or legal guardian of the child named above and that I have the authority to enter into this agreement on behalf of my child. I have read and fully understand the contents of this release.

Child's Name(Required)

Student Full Name

Date(Required)

MM slash DD slash YYYY

Child's Name(Required)

Child's Full Name

Parent or Guardian (if under 18)(Required)

Parent's Full Name

Submit your application

After reviewing, and making sure all required fields are filled in, are you ready to submit your application?

Yes

This field is for validation purposes and should be left unchanged.

Fifth District Youth Advisory Council – Application

FIFTH DISTRICT YOUTH ADVISOR COUNCIL - APPLICATION PACKET

I. Application

II. 2025 – 2026 Parent or Guardian Consent and Waiver Claims Form

Child's Medical Information

III. 2025 – 2026 Photographic and Video Release and Consent Form

Submit your application

My Office

Connect with me

© Copyright 2025- Fifth District Supervisor Vianey Lopez

Fifth District Youth Advisory Council – Application

FIFTH DISTRICT YOUTH ADVISOR COUNCIL - APPLICATION PACKET

I. Application

II. 2025 – 2026 Parent or Guardian Consent and Waiver Claims Form

Child's Medical Information

III. 2025 – 2026 Photographic and Video Release and Consent Form

Submit your application

My Office

Connect with me

© Copyright 2025- Fifth District Supervisor Vianey Lopez

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