Youth Tour Entry Form
Please complete and submit this form by clicking on the "Submit Form" button below.
Please attach your contest submission, a recent color photo, and, if necessary, legal guardian documentation using the document upload tool at the end of the form. Detailed application instructions and requirements can be found on the website at
www.medinaec.org/youthtour
.
Essay Topic: What would life be like without electricity? How does it add value to our lives?
If you have any questions please visit MedinaEC.org, email
YouthTour@MedinaEC.org
or call 1-866-632-3532.
Fields with
*
are required fields.
Applicant Information
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First Name:
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Last Name:
Nick Name:
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Student's Phone No. (include area code):
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Student's Email Address:
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Mailing Address:
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City:
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State:
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Zip Code:
How did you hear about Medina EC's Youth Tour Program? (check all that apply)
TX Co-op Power
School
Bill Insert
Website
Social Media
Other
If "Other" is selected, please indicate source
"Other" Source:
*
Why are you applying to go on the Youth Tour trip?:
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What part of the trip are you looking forward to the most?:
School and Involvement Information
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High School or Home School Assoc.:
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School Street Address:
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School City:
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School Zip Code:
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School Telephone Number:
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Name of Principal:
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Grade Level:
Sophomore
Junior
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Intended Graduation Year:
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Name of Counselor:
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Future College Major of Interest:
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Career Goals:
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School Activities: Please list school activities you have participated in and any special honors you have received during your high school career, such as class officer, music, athletics, etc. Include the activity, the years you participated, and any relevant remarks.:
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Extra- Curricular Activities: Please list extra-curricular activities you have participated in, such as 4-H, FHA, church, community service clubs, etc. Include the activity, the years you participated and any relevant remarks.:
Parent/Legal Guardian Information
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Medina EC Member Number(s):
*
Name on Account (on latest bill):
Account Holder's Relationship to Applicant
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Relationship to Applicant:
Self
Parent
Legal Guardian
If not parent, the Legal Guardian must submit appropriate documentation (see checklist below for file upload tool).
*
The information below is required for at least one parent/legal guardian.
Legal Guardian/Mother's Name:
Phone Number (include area code):
Email Address:
Legal Guardian/Father's Name:
Phone Number (include area code):
Email Address:
Documentation Upload (maximum file size is 50 MB)
*
Upload your essay:
*
Upload your photo (JPEG/PNG acceptable):
Upload Legal Guardian documentation if applicable:
Acknowledgement and Authorization
I understand that by signing this document that I am giving Medina EC permission to use my/my child's photograph, name, and the contest submission (in its entirey or excerpts as determined by Medina EC) in any publication or medium the cooperative uses to promote the Medina EC Youth Tour program. All contest submissions become the property of Medina EC.
Click here to draw your signature.
Applicant's Signature
With your mouse, draw your signature. Then click Finish.
Date:
Click here to draw your signature.
Parent/Guardian Authorization Signature
With your mouse, draw your signature. Then click Finish.
Date:
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