Suffolk County Legislature Form Center

2. 
4. Suffolk County Legislator

   Find your Suffolk County Legislator, by visiting the Legislators page.

8. Participant Information
10. Name
12. Date of Birth

    Handwrite your DOB after printing the completed form.

13. Age
14. Gender
16. Address
18. City
19. State
20. Zip
22. Phone
23. Email
25. Parent's Names
27. School Attending
28. Grade
30. Affiliated Organization(s)

    Examples: 4-H, Boy Scouts, Girl Scouts, YMCA, etc.

32. Participant Signature

    Please sign after printing the completed form.

33. Date
    Date
37. Advisor Information
39. Advisor's Name
41. Advisor's Address
43. Advisor's Phone
44. Advisor's Email
48. Waiver & Agreement

    I agree to the following Distinguished Youth Award Program ("Program") rules and requirements:

    • I will select the activities I will perform in order to earn an award.
    • I will not attempt to perform an activity unless I am certain that I can perform it safely.
    • No one is authorized by the Program to: (1) advise a participant on the safety of an activity or whether a participant is prepared to perform it safely, or (2) supervise or exercise any control or authority over any participants.
    • I hereby release and hold harmless each of the individuals and legal entities involved in the Distinguished Youth Award Program from any and all liability of any kind for any injury I might suffer while performing an activity in connection with the Program.
    • Information about me and my participation in the Program may be publicized by the Program.
    • This agreement shall remain in effect as long as I am participating in the Program.
50. Participant's Name
51. Participant's Signature

    Please sign after printing the completed form.

52. Date
    Date
54. Parents/Guardians Acknowledgement

    We are the parents or legal guardians of the Distinguished Youth Award participant listed above. We have read the foregoing Waiver and Agreement and agree on behalf of ourselves and the participant to the terms thereof. We will assure that the participant is aware of the risks involved in each activity and we will take full responsibility in lieu of the Program for each activity.

    Required for all candidates who are not considered adults under New York State Law - generally all who are under 18 years of age.

56. Parent's Name
57. Parent's Signature

    Please sign after printing the completed form.

58. Date
    Date
62. Candidate Name
64. I am registering for:

    1. Bronze Medal

    1. Silver Medal

    1. Gold Medal
66. Select the Program Area(s) that you will be participating in:

    1. Volunteer Service

    1. Expedition

    1. Personal Development

    1. Physical Fitness
68. Briefly describe the issues that you plan to address for each of the selected Program Areas:
70. Provide a detailed plan of activities that will be performed to accomplish the goals set for the selected Program Areas:

72. Please print legibly or type (make copies as needed).

76. Send Completed Form to:

    The Distinguished Youth Award
    Office of Presiding Officer Robert Calarco
    Suffolk County Legislature
    P.O. Box 6100
    Building 20
    Hauppauge, NY 11788-0099

    (Please fill out Date of Birth and signatures after printing the form)

77. If you prefer to fill out your registration/application using our fillable PDF, please click the link below.
    Registration/Application PDF

    Please print legibly or type (make copies as needed).

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78. Print Only

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