Youth Tour Student Registration Page

First Name *

Middle Initial *

Last Name *

Are you a winner / alternate / "Willie Wiredhand" participant? *

If you are an Alternate and wish to go on the trip as a Willie Wiredhand - click Willie Wiredhand.

If you are an alternate and want to go as a Willie Wiredhand (paying you own way if the winner goes) please make note here.

First Name (to be printed on Name Badge)

(First Name as you want it to appear on your name badge - if you go by a different name other than your given name)

Date of Birth mm/dd/yyyy *

Cooperative Name *

Gender *

Male

Female

Age on first day of trip (June 17) *

US Citizen *

Yes

No

Country of Citizenship *

City and State or Country of Birth (i.e. Springfield, IL or Canada) *

(City and State/or Country of Birth)

Participant's Cell Number (enter as XXX-XXX-XXXX) (that will be carried on the trip) *

Home Phone Number if you have one (enter as XXX-XXX-XXXX) *

If you do not have a home land line - enter N/A

Phone number to be used in Youth to Washington brochure *

Would it be ok for the trip advisors to contact the participant by text message during the trip? *

Yes

No

Address *

City *

No Spaces (ex: Los Angeles = LosAngeles)

State *

Zip Code *

Parent or Guardian's Email Address *

Participant's Email Address *

Can we use participant's email in the booklet? *

Yes

No

Participant's T-shirt Size - (unisex sizes) *

S

M

L

XL

XXL

XXXL

Participant's Polo shirt Size (women's and men's sizes used) *

S

M

L

XL

XXL

XXXL

Does participant have health insurance? *

Yes

No

Parent/Guardian Contact Information

First - Parent/Guardian (first and last name)

Relationship to student - First Parent or Guardian

Best Phone Number to Reach First Parent/Guardian (xxx-xxx-xxxx)

Second - Parent/Guardian (first and last name)

Relationship to student - Second Parent or Guardian

Best Phone Number to Reach Second Parent/Guardian (xxx-xxx-xxxx)

Washington Youth Tour -- Emergency Contact -- OTHER THAN PARENT OR GUARDIAN

List the names and telephone numbers of two individuals, OTHER THAN YOUR PARENTS OR GUARDIANS, who can be contacted in case of an emergency - this will be used if staff can not contact your parents or guardians. Staff will try to contact parents or guardians first.

First Emergency Contact (other than Parent or Guardians) Name (First - Last Name) *

Contact 1

First Emergency Contact - Relationship to participant *

Contact 1

Best Phone Number (enter as XXX-XXX-XXXX) to reach First Emergency Contact *

Contact 1

Does contact 1 have a work phone number? If yes, please list in the following field. *

Yes

No

First Emergency Contact's - Work Phone Number (enter as XXX-XXX-XXXX) *

Contact 1

Second Emergency Contact (other than Parent or Guardian) Name (First - Last Name) *

Contact 2

Second Emergency Contact - Relationship to participant *

Contact 2

Best Phone Number (enter as XXX-XXX-XXXX) to reach Second Emergency Contact *

Contact 2

Does contact 2 have a work phone number? If yes, please list in the following field. *

Yes

No

Second Emergency Contact's - Work Phone Number *

Contact 2

Washington Youth Tour -- Medical Information

List any allergies for which you take medication, or any other medical condition for which medication would be needed for the trip (i.e. diabetes, car sickness, pregnancy, etc.). Also, please list any chronic or temporary medical conditions (such as pregnancy, epilepsy, diabetes, etc.) that the tour director and chaperones should be aware of.
If a new medical condition occurs prior to Youth Tour contact Ashley Graham: agraham@aiec.coop or call 217-241-7916.
IF APPLICABLE Do you have any of the following:

Asthma *

Yes

No

Please describe your Asthma if Necessary

Convulsions / seizures *

Yes

No

Please describe *

Respiratory Problems *

Yes

No

Please describe *

Diabetes *

Yes

No

Please describe *

Bleeding Problems *

Yes

No

Please describe *

High blood pressure *

Yes

No

Please describe *

Heart murmur / heart disease *

Yes

No

Please describe *

Pregnant *

Yes

No

Please describe *

Depression disorder *

Yes

No

Please describe *

Food Allergies

Yes

No

Please specifically describe your food allergy

Dietary Restriction *

If you have a religious dietary restriction please list here

Please provide additional information - explaining the restriction

Do you take any medications *

Yes

No

Medication description ---- Medications: Please explain in detail any physical disability, limitations, etc, or any medication or treatment being taken by the student. List drug name and dosage of medications you take regularly. PLEASE WRITE “ NONE ” IF APPLICABLE. *

Washington Youth Tour -- Insurance Data

Note: This information is required for the Accidental Insurance Coverage provided by the AIEC for the participant.

Full Name of Participant *

Full Name of Beneficiary *

Address of Beneficiary *

City *

State *

Zip Code *

Relationship to Participant *

Next Step

Complete the Student Medical Release via the link provided. Print the Rules and Expectations & Social Media Contract forms. Return them signed by parent(s) or guardian(s) and student to Ashley Graham by May 2, 2022.

Member Sign In

Parent/Guardian Contact Information

Washington Youth Tour -- Emergency Contact -- OTHER THAN PARENT OR GUARDIAN

Washington Youth Tour -- Medical Information

Washington Youth Tour -- Insurance Data

** Next Step **

Next Step