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Youth Tour Application Forms

Students will need a digital photo, as well as, photos or scanned copies of their identification and insurance cards to complete registration. Please have them before filling out the forms.

Step 1 of 5 - Medical Information & Release

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Your sponsoring electric cooperative, Arkansas Electric Cooperative Corporation (AECC), and the National Rural Electric Cooperative Association (NRECA) collect the information contained in this form to provide or arrange first aid and other medical treatments for participating students of the Electric Cooperative Youth Tour to Washington. We reserve the right to refuse participation to your child in the tour in the event you refuse to provide the requested information. The information collected will be kept by AECC and NRECA staff and made available to medical staff in the case of an accident or emergency. This information is not shared for any other purpose.
Medical Information & Release
Student Name:*
First Middle Last
Age:*
Parent(s) Name:*
Home Phone #:*
Work Phone #:*
In case of emergency, contact:*
Phone Number:*
Name of Family Physician:*
Ph. #:*
Do you have medical insurance:*
- Yes
- No
Name of medical insurance company:*
Policy No.:*
Phone number of medical insurance authorization:*
PLEASE LIST ALL PRESCRIPTION MEDICATIONS THAT YOU ARE CURRENTLY TAKING:
PLEASE LIST ANY MEDICATION THAT YOU ARE OR MAY BE ALLERGIC TO:
List food allergies, if any:
LIST ANY ILLNESSES THAT YOU HAVE AND ALL CONDITIONS AND/OR TREATMENT FOR WHICH YOU ARE CURRENTLY UNDER THE CARE OF A PHYSICIAN OR ARE UNDER MEDICAL SUPERVISION. PLEASE LIST ALL MEDICAL CONDITIONS OR PROBLEMS THAT MAY REQUIRE SPECIAL CARE OR ATTENTION:
SOME MEDICAL CONDITIONS MAY REQUIRE A DOCTOR’S CERTIFICATE OR MEDICAL CLEARANCE PRIOR TO THE TOUR, WHICH STARTS June 14, 2019. THE UNDERSIGNED HEREBY RELEASES AND FOREVER DISCHARGES ARKANSAS ELECTRIC COOPERATIVE CORP., ITS BOARD, OFFICERS AND EMPLOYEES AND
Electric Cooperative's Name*
ITS BOARD, OFFICERS AND EMPLOYEES FROM ANY AND ALL CLAIMS, CAUSES OF ACTION OR LIABILITY, WHETHER KNOWN OR UNKNOWN, RELATING TO ANY MEDICAL CONDITION EXISTING ON THE DATE HEREOF, WHICH CLAIMS, CAUSES OF ACTION OR LIABILITY ARISE OR RESULT FROM PARTICIPATION IN THE ELECTRIC COOPERATIVE YOUTH TOUR. I/WE ALSO AGREE TO INDEMNIFY AND HOLD HARMLESS THOSE PERSONS OF THE ABOVE STATED ORGANIZATIONS AND SAID ABOVE STATED ORGANIZATIONS ON ANY CLAIMS FOR DAMAGES, LIABILITY, INJURY, EXPENSE, OR LOSS ARISING OUT OF THE ELECTRIC COOPERATIVE YOUTH TOUR.

I certify that I have answered the above questions as accurately as possible, and that all known medical information about this student has been listed accordingly and that I/we have read, understand and acknowledge that I/we are releasing Arkansas Electric Cooperative Corporation and
Electric Cooperative's Name*
from any and all claims, causes of action and liability which, may arise as a result of said medical conditions which were listed or should have been listed above.

In addition, in case of accident or need for medical attention I/we give permission to the Electric Cooperative Youth Tour staff to take participant
Participant's Name:*
to a doctor and/or medical facility. (It being understood that all expenses for treatment provided will be borne by the parent, guardian, or participant.)
Signature of Parent or Guardian:*
Signature of Student:*
We hereby release and agree to hold harmless Arkansas Electric Cooperative Corporation and NRECA, their officers, members, staffs, and associated organizations together with their heirs, successors, or assigns from any and all causes of action, claims, damages, costs, expenses, compensation, personal injury, property loss, or any other loss or injury related to participation by my/our son/daughter during his/her participation in the Electric Cooperative Youth Tour.

Custody Release for Airport Pick-Up
Who will pick your child up at the airport?*
I/we, the undersigned parent(s), desire that our child,*
shall be released into the custody of the above named person upon arrival at the Bill and Hillary Clinton National Airport in Little Rock on June 14, 2019.

It is also understood and agreed that by signing this document, we are waiving any and all rights to recover damages due to Arkansas Electric Cooperative Corporation, its directors, officers and/or agents releasing said child into the custody of the person listed above.

It is our understanding the above named custodian will present a photo I.D. upon arrival.
Parent or Guardian Signature:*
We hereby release and agree to hold harmless Arkansas Electric Cooperative Corporation and NRECA, their officers, members, staffs, and associated organizations together with their heirs, successors, or assigns from any and all causes of action, claims, damages, costs, expenses, compensation, personal injury, property loss, or any other loss or injury related to participation by my/our son/daughter during his/her participation in the Electric Cooperative Youth Tour.

Designation of Beneficiary
Arkansas Electric Cooperative Corporation purchases accident insurance coverage for each Youth Tour participant that is effective from the time the participant leaves his/her residence to participate in the tour until he/she returns to Little Rock. This form names a beneficiary for the $10,000 benefit.
Name of Participant:*
Street/Rural Route./P.O. Box:*
Street Address City State ZIP Code
I do hereby designate:
Name of Beneficiary:*
This is usually a parent or guardian
Address:*
Street Address City State ZIP Code
as my insurance beneficiary during the 2019 Electric Cooperative Youth Tour during the week of June 14-20, 2019.

I understand that this insurance, purchased by Arkansas Electric Cooperative Corporation will be in effect from the time I leave Little Rock, Ark., on said Youth Tour until the time I return to Little Rock, Ark., from Washington, D.C., on said Youth Tour.
Signature of Participant:*
We hereby release and agree to hold harmless Arkansas Electric Cooperative Corporation and NRECA, their officers, members, staffs, and associated organizations together with their heirs, successors, or assigns from any and all causes of action, claims, damages, costs, expenses, compensation, personal injury, property loss, or any other loss or injury related to participation by my/our son/daughter during his/her participation in the Electric Cooperative Youth Tour.

Personal Data
Make sure the name you enter matches the name on your official drivers license or identification card.
Sponsoring Electric Cooperative*
Name*
First Middle Last
Age:*
Birthdate:*
Address*
Street Address Address Line 2 City State ZIP Code
Preferred Name for Nametag:*
Email Address:*
Cell Phone/Student:*
U.S. Citizen:*
- Yes
- No
If no, what is country of origin:*
Gender:*
- Male
- Female
Parent(s) Guardians Name(s):*
Phone number (s) for father or guardian:*
Phone number (s) for mother or guardian:*
Shirts

Students will be provided shirts for each day of the trip. T-shirts will be worn most days. T-shirts will be in provided in unisex sizes. On the day we take photos with our Congressional delegation, we will wear polo-style shirts. These polo-style shirts are offered in a ladies’ cut which can sometimes differ from unisex T-shirt sizes. For the female students whose T-shirt sizes may differ from ladies’ fit polo shirts, please indicate the correct size for both.
T-Shirt Size*
- Small
- Medium
- Large
- Xlarge
- XXlarge
- XXXLarge
Ladies' Cut Polos (Ladies Only)*
- Small
- Medium
- Large
- Xlarge
- XXlarge
- XXXLarge
School activities, honors, awards, offices held, etc.*
List any public speaking experience:*
Hobbies, special interests:*
What is your career goal:*
Digital Photo*
We need a digital portrait photograph of you for our delegate directory.

Upload your 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 a 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 medical insurance card here:
Signature of Student:*
We hereby release and agree to hold harmless Arkansas Electric Cooperative Corporation and NRECA, their officers, members, staffs, and associated organizations together with their heirs, successors, or assigns from any and all causes of action, claims, damages, costs, expenses, compensation, personal injury, property loss, or any other loss or injury related to participation by my/our son/daughter during his/her participation in the Electric Cooperative Youth Tour.

Photo/Video Release
For good and valuable consideration, the receipt of which is hereby acknowledged, I hereby consent to the photographing of my minor child,
Child’s Name:*
and the recording of his/her voice and use of these photographs and/or recordings singularly or in conjunction with other photographs and/or recordings for advertising, publicity, commercial or other business purposes. I understand that the term "photograph" as used herein encompasses both still photographs and motion picture (video) footage.

I further consent to the reproduction and/or authorization by the Electric Cooperatives of Arkansas to reproduce and use said photographs and recordings for use in all domestic and foreign markets.

I hereby release the Electric Cooperatives of Arkansas and any of its member cooperatives, their trustees, directors, officers, agents, employees and customers, and appointed advertising agencies, their directors, officers, agents and employees from all claims of every kind on account of such use.
Printed Name of Parent:*
Signature of Parent:*
We hereby release and agree to hold harmless Arkansas Electric Cooperative Corporation and NRECA, their officers, members, staffs, and associated organizations together with their heirs, successors, or assigns from any and all causes of action, claims, damages, costs, expenses, compensation, personal injury, property loss, or any other loss or injury related to participation by my/our son/daughter during his/her participation in the Electric Cooperative Youth Tour.

1 Cooperative Way / Little Rock, AR 72209
(501) 570-2200
communications@aecc.com

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