Youth Tour Submission Form

Thank you for your interest in the Rural Electric Youth Tour sponsored by Claverack Electric! The lucky students selected to participate will have the opportunity to explore Washington, D.C., with a group of their peers for a six-day sightseeing excursion that mixes fun and education. The dates for the 2017 Youth Tour are June 11-16.

Complete the webform below as instructed and submit by Friday, February 24, 2017. Please note that you must include either the video OR essay portion of the application, not both, and a wallet-sized photo must be uploaded to this form. If you have any questions or concerns, please contact Karen Evangelisti at 570-268-1332 or via email at karene@ctenterprises.org.

Student Information

Name *

Age *

Birthdate *

Address (Street, City, Zip) *

Telephone Numbers (home/cell) *

E-mail address *

Parent/Guardian Name(s) *

Claverack Account Number *

School Name and Address *

Major Study Interest *

Career Goal *

State Representative *

State Senator *

U.S. Representative *

How did you hear about Youth Tour? *

What do you hope to achieve on this trip if selected? *

List any health concerns that could affect you during the trip, including any medications to which you are allergic: *

Activities and Achievements

High School Activities

List activities you have participated in and years of involvement, as well as any special honors you have received during high school (class officer, plays, music, athletics, clubs, etc.)

Public Speaking Experience

List any public speaking experience you may have.

Community or Civic Involvement

List any extracurricular activities and years of involvement in which you have participated (4-H, church, community and service clubs, etc.)

Special Interests or Hobbies

List any interesting facts about yourself.

Submission Requirements

Please note that information submitted here may be used by the Cooperative for educational and promotional purposes.

U-Tube Video Link Address:

Essay (400 word maximum, only required if not submitting video link):

Wallet-sized photo

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Youth Tour Submission Form