PERSONAL PROFILE FORM

 

47th Texas Government-in-Action Youth Tour
June 14-22, 2012

Must submit by March 16, 2012

First Name

(as it appears on your drivers license)

 

    

Middle Name

(as it appears on your drivers license)

 

  

Last Name

(as it appears on your drivers license)

 

    

Age

      
Gender  

 

Name on Badge ( As you want it to appear on your name badge, i.e. first name or nickname )

 

    
Date of Birth  
Address    
City    
State    
Zip      
     

Cell Phone (taking on tour)

 

    

E-mail ( Youth Tor Participant's Emal .. Not Parents )

 

    

Are You a US Citizen ?

 

  

Driver's License No. or School ID

( If not available a copy of birth certificate will need to be submitted )

 

   Number :

T-Shirt Size

 

  

Name of Your U.S. Congressman (representative, not senator)

 

    
Sponsoring Cooperative Name    
Phone    
Cooperative Coordinator Name    

Cooperative Coordinator Cell Phone

 

    
Name of Parent /Guardian    
Parent or Guardian Home Phone    

Parent or Guardian Business/Cell Phone

 

    
Name of Other Relative To Be Contacted in Case of Emergency  
Relationship  

Other Relative Phone

 

    
High School Attended  
Activities, Offices, Honors (school, community and church)  
Hobbies and special interests (this will assist with room assignments, please keep that in mind as you complete the form)  

 

 


 

**NOTE** If you press the submit button and nothing happens check your entries for errors