Chantal Bérubé Memorial Fund Youth of the Month Nomination Form

2. The Youth of the Month award is an honour presented to a youth who is either a resident of or student in Beaumont between the ages of 12 & 18.
4. Note
   Please complete the following information explaining how your nominee is simply an amazing youth. Chantal made sure to let young people know what they were doing right and how their contributions to our community made a difference. We want to keep that tradition alive in her honour and need your help. Tell us about your fantastic babysitter, reliable employee, dedicated volunteer, or otherwise awesome youth. Each year a Youth of the Year will also be chosen from the monthly award recipients.
6. I would like to nominate the following person for Beaumont’s Youth of the Month award in memoriam of Chantal Bérubé.
8. Name*
10. Age*
11. School they attend*
13. Phone Number*
14. Email Address*
16. Please describe why you are nominating this person*
18. Nominator Details
20. Nominator’s Name*
22. Nominator’s Phone Number*
23. Nominator’s Email Address*
25. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
27. Electronic Signature*
29. FOIP ACT
    The personal information contained on this form is being collected in order to select Youth of the Month on behalf of FCSS and CBYC. It is protected by the privacy provision of the FOIP Act. If you have any questions about the collection, contact the FOIP Coordinator at the City of Beaumont, 5600 - 49 Street, telephone 780-929-8782.
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field