Find your Suffolk County Legislator, by visiting the Legislators page.
Handwrite your DOB after printing the completed form.
Examples: 4-H, Boy Scouts, Girl Scouts, YMCA, etc.
Please sign after printing the completed form.
I agree to the following Distinguished Youth Award Program ("Program") rules and requirements:
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.
Please print legibly or type (make copies as needed).
The Distinguished Youth AwardOffice of Presiding Officer Robert CalarcoSuffolk County LegislatureP.O. Box 6100Building 20Hauppauge, NY 11788-0099
(Please fill out Date of Birth and signatures after printing the form)
* indicates a required field