2017 GOVERNMENT-IN-ACTION YOUTH TOUR
June 7–16
Congratulations
on being selected to represent your local electric cooperative and
the great state of Texas on the 2017 Government-in-Action Youth Tour.
As a participant on the Youth Tour, you MUST do the following by March 3, 2017:
u Complete the online Personal Profile.
u Submit the following: A completed copy of this form.
A copy of your drivers license or official Texas DPS identification card.
A copy of the front and back of your current health insurance card.
A headshot photo in jpg format.
If you are interested in representing Texas on the NRECA Youth Leadership Council and/or participating in the wreath-laying
ceremony at the Tomb of the Unknown Soldier, please also complete those pages.
Please be sure all copies are clearly legible. Scanning and submitting via email is preferred.
Documents may be submitted via:
Email: [email protected] (preferred)
Fax:
(512) 763-3378
Mail: Esther Dominguez
Texas Electric Cooperatives
1122 Colorado St., 24th Floor
Austin, TX 78701
2017 Youth Tour Participant’s Name: _______________________________________________________________________
Sponsoring Electric Cooperative: __________________________________________________________________________
Youth Tour Participant ______________________________ Sponsoring Electric Co-op _____________________________
Electric Cooperative Youth Tour—Emergency Contact
List the names and telephone numbers of two individuals, other than your parents or guardians, who can be contacted in case of
an emergency:
____________________________________________________________________________________________________
Name
Relationship
Home Phone
Cell
____________________________________________________________________________________________________
Name
Relationship
Home Phone
Cell
Electric Cooperative 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. Do you have any of the following:
Condition
Check One
Medications/Treatment: List specifics.
Food
__Yes __No
To what?
Medicine
__Yes __No
To what?
Environmental
__Yes __No
To what?
Anxiety/Depression/Other
__Yes __No
Sleeping Disorders
__Yes __No
Convulsions/Seizures
__Yes __No
Vision/Hearing Impairment
__Yes __No
ALLERGIES:
Bring Glasses/Contacts
Sinus or Ear Concerns
__Yes __No
Asthma/Breathing Concerns
__Yes __No
Bleeding Concerns
__Yes __No
Heart Murmur/Heart Disease
__Yes __No
High Blood Pressure
__Yes __No
Implanted Devices
__Yes __No
Diabetes
__Yes __No
Stomach or GI Concerns
__Yes __No
Pregnancy or Bladder
Concerns
__Yes __No
Muscles/Bone Concerns
__Yes __No
Bring Braces, Splints or Wraps
Recent Surgeries
__Yes __No
Vegan Meals
__Yes __No
Youth Tour Participant ______________________________ Sponsoring Electric Co-op _____________________________
Electric Cooperative Youth Tour—Student Insurance Data
Note: This information is required for the Accidental Insurance Coverage.
____________________________________________________________________________________________________
Full Name of Insured Youth
____________________________________________________________________________________________________
Full Name of Beneficiary
Relationship to Insured Youth
____________________________________________________________________________________________________
Address of Beneficiary
City and State
ZIP
Consent for Tour Participation and Medical Treatment
and Liability and Publicity Release Form
I/We the undersigned parent(s) or guardian(s) of _____________________________________________________________
Youth’s Full Name
give my/our consent for him/her to participate in the Electric Cooperative Youth Tour June 7, 2017, through June 16, 2017,
sponsored by _______________________________________________________________ and Texas Electric Cooperatives.
Sponsoring Electric Cooperative
I/We understand that this participation involves travel within and outside Texas, and at times my/our son/daughter may be traveling and/or participating in activities without the direct supervision of a chaperone. I/We authorize and direct Texas Electric
Cooperatives through their staffs and volunteer chaperones, to direct and supervise my/our son/daughter. I/We further request
and authorize Texas Electric Cooperatives, and through their staffs and volunteer chaperones, to secure any medical or other
emergency services the said staffs and volunteer chaperones in their reasonable discretion may deem necessary or desirable for
my/our son/daughter during his/her participation in the Electric Cooperative Youth Tour.
I/We hereby release and agree to hold harmless Texas Electric Cooperatives and _____________________________________
Sponsoring Electric Cooperative
and 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 participating by my/our son/daughter during his/her participation in the Electric Cooperative Youth Tour.
I/We hereby grant permission to Texas Electric Cooperatives and _________________________________________________
Sponsoring Electric Cooperative
to use photographs, likenesses and/or video images of my/our son/daughter for publicity purposes related to this activity.
____________________________________________________________________________________________________
Parent/Legal Guardian’s Signature
Parent/Legal Guardian’s Signature
____________________________________________________________________________________________________
Date
Date
Youth Tour Participant ______________________________ Sponsoring Electric Co-op _____________________________
Youth Tour Expectations and Guidelines
You were selected by your sponsoring electric cooperative to
join the 52nd annual Texas Government-in-Action Youth Tour
because you have measured up to the highest standards of
leadership and behavior. You will be representing your local
cooperative, all the cooperatives in Texas, your local community and the state of Texas from the kickoff banquet to the
closing celebration in Irving. You have a responsibility to yourself and others to meet the following expectations.
Participants may not possess or use alcoholic beverages,
drugs, tobacco or weapons (such as firearms, fireworks, knives
or any other type of weapon). If you normally carry a pocketknife, you will want to leave it at home for this trip.
Respect the rights of others. You will share a room with other
Youth Tour delegates and are expected to be tolerant of any differences. After curfew, you will be expected to stay in your room
and be reasonably quiet so that others may sleep.
Have a positive attitude and remain flexible. The nature of
travel, combined with the size of our group, will mean constant
adjustments. How you react to these adjustments will have a
lot to do with what this experience will mean to you in the
end. Stay flexible and enjoy every minute of this experience.
Know where you are supposed to be. Participants need to pay
attention to designated gathering points at the end of each
activity. You are responsible for being at each gathering point
at or before the specified time.
Be punctual. The schedule is super-tight. We want to experience as much as we can, so wear a watch and be on time.
Participants should immediately report to the Tour director or
a chaperone any activities and/or statements made by other
participants that may endanger the health or safety of anyone.
Participate in all planned activities. No one may leave the
group at any time unless authorized by a chaperone. There
must always be at least three people in a group at all times.
Participants who violate local, state or federal laws will be
turned over to the appropriate legal authorities for prosecution.
Adhere to the dress code, which includes wearing your name
badge and appropriate attire at all times during the Tour.
Participants will abide by any and all verbal instructions
issued by the Tour director, staff and chaperones.
Respect curfews. Be in your hotel room by curfew each night.
Curfew is 10:30 p.m., and you must be in your room at that
time. No exceptions unless approved by a chaperone.
Cellphones are permitted and are a good way to stay in touch
during the Tour. It is important, however, that each participant is
attentive during Tour hours; therefore, cellphone use should be
limited. Cellphones may be used while in your hotel rooms or
when we have free time. During room check, all cellphones
should be turned off while your chaperone is in the room. Be
respectful of your roommates and limit conversations after room
check. It is not appropriate to sit in the hall and talk on your cellphone for long periods. Cellphone use will be monitored and
phones will be confiscated if guidelines are not followed.
Room checks will be performed each night. Chaperones will
do room checks and they must see everyone assigned to each
room. Chaperones will go over the schedule for the following
day and do a general check on how the day was and address
any concerns or questions.
Boys’ rooms are for boys; girls’ rooms are for girls. Under no
circumstance shall boys enter girls’ rooms or girls enter boys’
rooms. If this happens, there will be no questions asked—
participants will be sent home at the expense of their parents.
Hotel property must remain at the hotel. Do not take hotel
property as souvenirs. Also, any damage to hotel property will
result in payment of damages by the responsible party and an
immediate trip home at the expense of your parents.
It will be the responsibility of each participant to keep up
with their personal belongings. Items left or misplaced should
be considered gone. This includes cellphones, iPods, etc.
CD players, MP3 players and iPods are allowed but an important goal of this trip is for you to interact with the other delegates (not isolate yourself with your music). You may only
listen to these devices at the hotel in your off hours. You may
not use them on the bus or during any tours. If you violate
these rules, the device will be confiscated.
By our signatures below, we acknowledge that we have read,
understand and will adhere to these expectations.
_________________________________________________
All participants must have a photo ID (drivers license or school
photo ID). The ID should be carried with you at all times.
Youth Tour Participant Signature
You may not leave the hotel except for planned outings. You
may not leave the hotel to visit relatives or friends.
_________________________________________________
Parent/Legal Guardian Signature
Youth Tour Participant ______________________________ Sponsoring Electric Co-op _____________________________
NRECA Youth Leadership Council Application Form
TEXAS
As part of the 2017 Texas Youth Tour delegation, you have the chance to represent Texas on the NRECA Youth Leadership Council
(YLC) and attend the YLC Leadership Conference in July 2017. The purpose of the conference is to build leadership and public
speaking skills, and to enhance the delegates’ knowledge of the energy industry and the cooperative form of business. YLC delegates are also expected to attend NRECA’s Annual Meeting in February 2018 and to make presentations at statewide and local
electric cooperative meetings. YLC delegates gain poise, confidence and have opportunities to develop other leadership skills to
improve their communities and make their country a better place.
THIS FORM IS OPTIONAL. Complete only if you’d like to be considered for the NRECA Youth Leadership Council.
Please DO NOT complete this form if you will be unable to attend both of the following events:
Youth Leadership Conference in Washington, DC, July 15-19, 2017.
2018 NRECA Annual Meeting in Nashville, Tennessee, February 22–March 2, 2018. YLC members need to arrive on Saturday,
February 24, and will depart Wednesday, February 28.
Name _______________________________________________________________________________________________
Phone (____)______________________________________ Cell (____) _________________________________________
Address _____________________________________________________________________________________________
City/State/ZIP ________________________________________________________________________________________
E-Mail_______________________________________________________________________________________________
Age__________________ Date of Birth ___________________________________________________________________
Shirt Size (circle one):
Small
Medium
Large
Parent(s)/Guardian(s) Name(s) ___________________________________________________________________________
Mother
Father
Emergency Contact ___________________________________________________________________________________
Name, relationship and phone
City and Airport Closest to Your Home (Please be as precise as possible. In doubt ask your parents.)______________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Approximate Driving Time to Airport: ______________________________________________________________________
Name and Address of Local Newspaper ____________________________________________________________________
____________________________________________________________________________________________________
Sponsoring Electric Cooperative___________________________________________________________________________
Address _____________________________________________________________________________________________
City/State/ZIP ________________________________________________________________________________________
Contact at Sponsoring Electric Cooperative _______________________________ Phone (_____)______________________
Contact at TEC Esther Dominguez, (512) 961-2875, [email protected]
Youth Tour Participant ______________________________ Sponsoring Electric Co-op _____________________________
NRECA Youth Leadership Council Application continued
PART I—SCHOOL INFORMATION
Name and Address of School _____________________________________________________________________________
____________________________________________________________________________________________________
Telephone (______)_________________________________ Fax (______) ______________________________________
Principal _____________________________________________________________________________________________
Current Grade ____________________________ Scholastic Standing Last Year ____________________________________
Major Study Interest ___________________________________________________________________________________
Career Goal __________________________________________________________________________________________
Please list activities you have participated in and any special honors you have received during your high school career, such as
class officer, plays, music, athletics, etc.
ACTIVITY
YEAR(S)
REMARKS
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____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
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____________________________________________________________________________________________________
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____________________________________________________________________________________________________
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____________________________________________________________________________________________________
____________________________________________________________________________________________________
Youth Tour Participant ______________________________ Sponsoring Electric Co-op _____________________________
NRECA Youth Leadership Council Application continued
PART II – EXTRA-CURRICULAR ACTIVITIES
List extra-curricular activities and years of involvement, such as 4-H, FHA, FFA, church, community, service clubs, etc.
ACTIVITY
YEAR(S)
REMARKS
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Please list any public speaking experience.
Please list any writing experience, such as school newspaper, yearbook, etc.
Youth Tour Participant ______________________________ Sponsoring Electric Co-op _____________________________
Tomb of the Unknown Soldier Wreath-Laying Ceremony 2017
THIS FORM IS OPTIONAL.
The Tomb of the Unknown Soldier is a monument dedicated to American service members who have died without their remains
being identified. The Tomb honors Americans who gave their lives in World War I, World War II and the Korean and Vietnam
Wars in defense of our nation. Numerous ceremonies are performed annually at the Tomb to honor these soldiers and to show
the nation’s respect for members of the United States Armed Forces.
Four Texas applicants will have the opportunity to participate in a wreath-laying ceremony at the Tomb. To apply for this opportunity, write a brief statement of why you would like to be part of the wreath-laying ceremony and why it would be signficant to
you to participate.