2018 Washington Youth Tour Electric Cooperatives of Arkansas Personal Data Form Step 1 of 3 33% Make sure the name you enter matches the name on your official drivers license or identification card. Sponsoring Electric Cooperative:*Cooperative Name 1Cooperative Name 2Cooperative Name 3Name* First Middle Last Age:*Birthdate:* Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Preferred Name for Nametag:*Email Address:* Cell Phone/Student:*U.S. Citizen:*YesNoIf no, what is country of origin:*Gender:*MaleFemaleParent(s) Guardians Name(s):*Phone number (s) for father or guardian:*Phone number (s) for mother or guardian:*Shirts:*SmallMediumLargeXlargeXXlargeXXXLarge School activities, honors, awards, offices held, etc.*List any public speaking experience:*Hobbies, special interests:*List all food allergies or dietary restrictions:*What is your career goal:* Digital Photo:We need a digital portrait photograph of you for our delegate directory. Upload photo here.*Driver’s License or Official State Identification:We need a scan or digital photograph of your driver’s license or official state identification. Upload scan or digital photograph of your identification here.* Medical Insurance Card:We need a scan or digital photograph of your medical insurance card. Upload scan or digital photograph of your identification here.*If you do not have medical insurance please indicate here.* I don't have medical insurance. Signature of Student:* Stacy Rinehart Arkansas Youth Tour Assistant Arkansas Electric Cooperative Corporation P.O. Box 194208 Little Rock, AR 72219-4208 501-570-2294 firstname.lastname@example.org This iframe contains the logic required to handle Ajax powered Gravity Forms.