Youth to Washington Trip Application | Eastern Illini Electric Cooperative

Student Information

First Name

Last Name

Address

City, State, Zip

Eastern Illini Electric Co-op Account Number

Mobile Phone Number

Can We Text You?

Email Address

Birthdate (mm/dd/yyyy)

Name of Parent or Guardian

Parent or Guardian's Mobile Number

Can We Text Your Parent or Guardian?

Parent or Guardian's Email Address

T-Shirt Size

School Information

High School

Current Grade in School

Grade Point Average (100 point scale)

If your school uses a 4.0 scale, please multiply your GPA by 25.

Personal Achievements (Both School and Non-School)

Additional Information

What Are Your Plans After High School?

Please list your work and volunteer history. List positions held, for what time period, and whether volunteer or for pay. Please do not make any reference to name or home location. (Example: "Volunteer at Big Brothers, Big Sisters, 2 years, Volunteer")

If You Could Change Anything About Your State, What Would It Be And Why?

Cooperatives Can Provide Any Needed Service Such As Electric, Telephone, Water, Food, Insurance, Etc. Explain A Benefit Of Being a Cooperative Member.

If You Win The Youth To Washington Program, You May Be Asked To Help Promote The Program To Fellow Classmates Next Year. Describe One Way You Would Promote The Program. Be Creative!

Digital Signature and Affirmation of Information

Student Affirmation

I have examined this application and to the best of my knowledge, it is true, correct, and complete.

Student Digital Signature

Parent/Guardian Affirmation

I the undersigned, being the parent/guardian of this applicant, do hereby agree that if this applicant is chosen as a winner, I grant permission for the applicant to take the expenses-paid trips to both Springfield, Illinois and Washington, D.C. as sponsored by Eastern Illini Electric Cooperative and the Association of Illinois Electric Cooperatives. I also understand that photos may be taken of the applicant, and I agree that those photos may be used to promote the Youth to Washington program.

Parent/Guardian Digital Signature

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