Electric Cooperative Youth Tour | South River Electric Membership Corporation

Name (first and last):

Name you go by:

Age:

Address

City/Town

ZIP/Postal Code

County of residence:

Student phone number: (xxx) xxx-xxxx

Student email address:

High school:

Current grade level:

Parent's names (first and last):

Parent's phone numbers:

Any allergies we should be aware of? If so, please list:

Who is your electric company?

Any possible conflicts with the scheduled dates for the Youth Tour?

Yes

If yes, please explain:

How did you learn about the Youth Tour?

What academic and extra-curricular activities are you involved in?

Academic and extra-curricular honors received:

Video upload:

videoupload2

grassroots video

Representative Video

Would you like to receive information on the Youth Leadership Council?

Yes