WYT Delegate Intake Form

Name*

First Middle Last

Name as you want it to appear on your name badge*

Delegate photo

For TECA's use only. Delegate's photo will be taken at orientation.

Accepted file types: jpg, png, Max. file size: 32 MB.

Delegate driver's license*

Please upload a scanned copy of the front and back of the delegate's drivers license.

Drop files here or

Accepted file types: jpg, png, Max. file size: 32 MB, Max. files: 2.

Sponsoring Electric Co-op*

Congressman*

If you are not sure, visit https://www.congress.gov/members/find-your-member .

County*

High School*

Gender

Date of Birth*

Age*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Mobile Phone

Will you be taking your cell phone on the trip?*

Yes
No

Can we send texts about WYT to your cell phone?*

Yes
No

Email*

T-shirt size*

Parents/Guardians

List the full names of your natural parents, step-parents, and/or legal guardians

Father/Guardian*

First Last

Home Phone

Mobile Phone

Mother/Guardian*

First Last

Home Phone

Mobile Phone

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

List

Name	Relationship	Phone

Medical Information

Do you have any of the following?

Asthma
Convulsions/seizures
Respiratory problems
Diabetes
Bleeding problems
High blood pressure
Heart murmur/heart disease
Pregnant
Depression

Please list any additional medical conditions we should be aware of

Medication

List drug name and dosage of medications you take regularly.

Food Allergies/Special Diet Restrictions

List any dietary needs (vegan, gluten intolerant, etc.)

Insurance Data

Note: This information is required for the Accidental Insurance Coverage. If you do not have health insurance, please select No. Health insurance will be provided for you during the trip.

Is the delegate have health insurance coverage?*

Yes
No

Full Name of Delegate

First Middle Last

Full Name of Beneficiary*

First Middle Last

Relationship to Insured Youth*

Address of Beneficiary*

Street Address Address Line 2 City State ZIP Code

Insurance Provider

Policy Number

Scan or photo of insurance card

IMPORTANT: You must send the front AND back of card

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 32 MB, Max. files: 2.

Parental/Guardian Consent

Consent for Medical Treatment, Liability, and Publicity Release*

I/We understand that this participation involves travel within and outside of Tennessee, and that 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 Tennessee Electric Cooperative Association, and NRECA, through their staff and volunteer chaperones, to direct and supervise my/our son/daughter. I/We further request and authorize Tennessee Electric Cooperative Association, and NRECA, through their staff and volunteer chaperones, to secure any medical or other emergency services that the said staff and volunteer chaperones in their reasonable discretion may deem necessary or desirable for my/our son/daughter during his/her participation in the Rural Electric Washington Youth Tour.

I/We hereby release and agree to hold harmless Tennessee Electric Cooperative Association, and NRECA, their officers, members, staff, 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 Rural Electric Washington Youth Tour.

I/We hereby grant permission to Tennessee Electric Cooperative Association, and NRECA to use photographs, likenesses, and/or videotape images of my/our son/daughter for publicity purposes related to this activity.

I/We, the undersigned, in our legal capacity as the parent or guardian of the child or ward described above, do herby certify that such child (print full name) ________________________(is or is not) vaccinated.

The undersigned will supply the above-described child or ward a negative COVID-19 test taken within three days of the applicable TECA Washington Youth Tour, when requested and as required by law. The undersigned do hereby further authorize and consent to my/our child or ward being required to submit to COVID-19 symptom checks, including COVID-19 tests, temperature checks, and any other symptom monitoring under CDC guidance. The undersigned do hereby acknowledge the uncertainty surrounding the continued COVID-19 pandemic and its potential effects on individuals and that its potential effects on individuals vary, both on a short term and long-term basis and are aware of the published CDC guidance. In that regard, the undersigned do hereby forever release, waive and discharge and the Tennessee Electric Cooperative Association, and their respective officers, directors, members, employees, and volunteers from and against any and all liability, losses, compensation, damages, actions, causes of action, claims, expenses (including medical expenses) and costs suffered or incurred by or on behalf of the above-named child or ward arising from or related to such child or ward contracting or becoming infected or ill with coronavirus or COVID-19 from attending or while attending any TECA Washington Youth Tour activity including, but not limited to, any related travel, activities, lodging activities, dining activities or otherwise.

I/We agree.

Mother's/Guardian's Signature

Father's/Guardian's Signature

Delegate Consent

Student Code of Conduct*

Delegates, please read these rules carefully. If these rules are broken you may be sent home at YOUR & YOUR PARENTS EXPENSE.

You will be sharing a room with two other students. Please be considerate of your roommates.

You may decide when to go to sleep each night, but you must be in your room by curfew and be on time each morning.

Students are not allowed to leave the hotel premises without a chaperone.

Male students are not permitted in female students’ rooms, nor are female students permitted in male students’ rooms, EVER!

Smoking, alcoholic beverages, or drugs not prescribed by a medical doctor are NOT allowed at any time.

Cell phones are allowed, but we ask that you only use them to take photos while we are touring. If you are texting, you may miss a “once in a lifetime opportunity”. You will have ample amount of time to text on the bus and in your room.

Participants must be clothed properly at all times.

No destruction of property is allowed. Any damages incurred above and beyond normal wear and tear will be charged to the participant causing the damage.

Students who cancel their participation after April 15th, 2022 may be required to cover any non-refundable costs incurred by the cooperative if an alternate cannot be found.

I have read and understand the Code of Conduct. I understand that as a participant of the Washington Youth Tour I am a representative of my cooperative and must conduct myself appropriately at all times. I understand that I may be sent home, at my expense, from the Youth Tour if I do not comply with these policies.

I agree.

Delegate's Signature

Phone

This field is for validation purposes and should be left unchanged.