LatinX Student Week- Gov Page Application

LatinX Governor Page Student Week
Student Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Date of Birth *

Month Day Year
Date
County where you reside: *
Are you available to participate in the page program September 13-16th? *

Yes No
If you are put onto the wait list, what other page week would you like to attend? Please list at least two. Remaining page weeks are listed on our website: https://governor.nc.gov/governors-page-program
Please share your activities, interests, honors, etc. *
Why are you interested in serving as a page? (Type at least 3 sentences) *
100 word minimum
We need at least one reference/recommender (non-family related) who we will be able to contact for your application
Reference

First Name Last Name
Phone Number of Reference

Area Code Phone Number
Email of Reference
example@example.com
Parent/Guardian Full Name *

First Name Last Name
Parent/Guardian Email *
example@example.com
Parent/Guardian Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Phone Number

Area Code Phone Number
Emergency Contact *

First Name Last Name
Emergency Contact Phone Number *

Area Code Phone Number
Should be Empty:

LatinX Governor Page Student Week