LatinX Student Week- Gov Page Application

LatinX Governor Page Student Week
Student Name*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Date of Birth*

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

YesNo
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 NameLast Name
Phone Number of Reference

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

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Phone Number

Area CodePhone Number
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Should be Empty:

LatinX Governor Page Student Week