WYT Intake Form

Delegate Information

Before you begin, here are a couple of things to know: Be sure to use proper capitalization and spelling when completing the form. You will need a photo that will be used for our records. Please provide something that includes head and shoulders, facing forward. You will need a photo of the front AND back of your insurance card as well as insurance information. We will also need a photo of the front and back of your drivers license or state issued ID.

This form is being completed for a*

High School Youth Tour Delegate

Teacher

Chaperone or co-op staff

Legal Name*

First Middle Last

Name as you want it to appear on your name badge

Gender*

Date of Birth*

Sponsoring Electric Cooperative*

It is very important that you select the correct electric cooperative. If you are not sure which co-op is sponsoring you, check with your school or find your co-op by using the interactive map on our website. Find your co-op.

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Traveler's Mobile Phone*

To ensure that chaperones can contact delegates during the trip, we do ask that each delegate bring a mobile phone. If the delegate does not have their own mobile phone, please contact your co-op chaperone.

Traveler's Email*

Enter Email Confirm Email

May we send you text/SMS updates via this number?

Yes

No

Name of School*

County*

Who is your member of Congress?

If you are not sure, search here.

T-shirt size*

Traveler's Photo

Please provide a photo that includes head and shoulders, facing forward.

Max. file size: 32 MB.

Traveler's driver's license*

Please upload a scanned copy of the front and back of the delegate's drivers license. This information is required to secure airline tickets.

Drop files here or

Max. file size: 32 MB, Max. files: 2.

Parent/Guardian Information

Parent Name 1*

First Last

Relationship*

Address

Street Address Address Line 2 City State ZIP Code

Parent Phone*

Parent Email*

Enter Email Confirm Email

Parent Name 2

First Last

Relationship

Address

Street Address Address Line 2 City State ZIP Code

Parent Phone

Parent Email

Enter Email Confirm Email

Emergency Contact Information

Emergency Contact Information*

List the names and telephone numbers of two individuals, other than your parents or guardians, who can be contacted in case of an emergency. Click the plus symbol to add additional lines.

Name

Relationship

Phone

Healthcare Information

Do you have any of the following?

To select more than one option, hold down Control on a PC or Command on a Mac, then click on your selections.

Please list any medications that you take

Please list any dietary restrictions

Please list any allergies

Please provide information on any medical conditions of which we should be aware

Does the traveler have health insurance coverage?**

Yes

No

Insurance Information*

Please upload a copy of the FRONT AND BACK of your medical insurance card. You can simply take a photo with your phone or submit a scanned photocopy.

Drop files here or

Max. file size: 32 MB, Max. files: 2.

Insurance Provider

Policy Number

Parent/Guardian Consent

Guardian Signature*

Name of Consenting Parent*

First Last

Date Consent Provided*

Chaperone/Teacher Consent

Chaperone/Teacher Signature*

Name of Chaperone/Teacher*

First Last

Date Consent Provided*

Delegate Consent

Delegate Signature*

Date Consent Provided*

Confirmation

Please take a moment to confirm your information. If everything is correct, please click Submit.

{all_fields}

CAPTCHA

2025 Washington Youth Tour

Delegate Information

Parent/Guardian Information

Emergency Contact Information

Healthcare Information

Parent/Guardian Consent

Chaperone/Teacher Consent

Delegate Consent

Confirmation