Missouri Youth Tour Delegate Form

Missouri Youth Tour Delegate Form
Delegate Name (Legal)*

First NameMiddle NameLast Name
First Name For Your Badge ID*
Sponsoring Electric Cooperative*
High School*
Birth Date*

MonthDayYear
Age*
Gender*
Shirt Size (unisex)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Your Congressperson*

District 1 – Wesley BellDistrict 2 – Ann WagnerDistrict 3 – Bob OnderDistrict 4 – Mark AlfordDistrict 6 – Sam GravesDistrict 7 – Eric BurlisonDistrict 8 – Jason Smith
Delegate E-mail*
We will send important trip updates and information to this address!
Secondary Delegate E-mail*
Non-school or parent email address
Delegate Mobile Phone Number*
For communication during the trip.
Father's Phone Number
Mother

First NameLast Name
Mother's Phone Number
Step-Father

First NameLast Name
Step-Father's Phone Number
Step-Mother

First NameLast Name
Step-Mother's Phone Number
Legal Guardian

First NameLast Name
Legal Guardian's Phone Number
Who do you live with?
Father
Emergency Contacts

List the full names and telephone numbers of one or two individuals, other than your parents or guardians, who can be contacted in case of an emergency.
Emergency Contact #1

First NameLast Name
Emergency Contact #1 - Phone Number
Please enter a valid phone number.
Emergency Contact #1 - Relationship
Emergency Contact #2

First NameLast Name
Emergency Contact #2 - Phone Number
Please enter a valid phone number.
Emergency Contact #2 - Relationship
We need your photo! A selfie or digital download of your school picture will work fine. Must be clear with your face fully visible.*

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For any questions, please contact Chris Massman at 573-659-3437
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Missouri Youth Tour Delegate Form

Emergency Contacts

For any questions, please contact Chris Massman at 573-659-3437