Home Youth Tour Student Registration Page Youth Tour Student Registration Page First Name * Middle Initial * Last Name * Are you a winner / alternate / "Willie Wiredhand" participant? * Winner Alternate "Willie Wiredhand" 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 * Adams Electric Cooperative Adams Telephone Co-Operative Clay Electric Co-operative, Inc. Clinton County Electric Cooperative, Inc. Coles-Moultrie Electric Cooperative Corn Belt Energy Corporation Eastern Illini Electric Cooperative Egyptian Electric Cooperative Association EnerStar Electric Cooperative Illinois Electric Cooperative Jo-Carroll Energy, Inc. (NFP) M.J.M. Electric Cooperative, Inc. McDonough Power Cooperative McDonough Telephone Cooperative, Inc. Menard Electric Cooperative Mid Century Telephone Co-operative Monroe County Electric Co-Operative, Inc. Norris Electric Cooperative Rock Energy Cooperative Rural Electric Convenience Cooperative Co. Shelby Electric Cooperative SouthEastern Illinois Electric Cooperative, Inc. Southern Illinois Electric Cooperative Tri-County Electric Cooperative, Inc. Wabash Telephone Cooperative, Inc. Wayne-White Counties Electric Cooperative Western Illinois Electrical Coop. Gender * Male Female Age on first day of trip (June 17) * US Citizen * Yes No Country of Citizenship * Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Congo (DRC) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe 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 * Home Cell None 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 * AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code * Parent or Guardian's Email Address * 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: email@example.com 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 * No dietary restriction Gluten Allergy Vegetarian Vegan Other 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 * AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY 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.