CYCLE Delegate Form

CYCLE Delegate Form
Delegate Name (Legal)*

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

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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.
Parent/Guardian Information

List the full names of your natural parents, step-parents and/or legal guardians in the section below. (Some fields may not be applicable)
Father

First NameLast Name
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?
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
Will the CYCLE participant require regular medication (prescription, over-the-counter, inhaler, etc.) while attending CYCLE?*
Please list information for the participant's medication below making sure to detail any potential side effects or other concerns - including what could happen if a dose is missed.
Does the participant have food, drug, or other allergies?*
Please provide details for all allergens, including seasonal allergies, along with the participant's potential reaction and the detailed action plan, as directed by the participant's doctor:
Does the participant have any dietary restrictions or requirements?*
Please list any dietary restrictions, preferences, and requirements:
Please list any medical issues that may require special consideration or care by the chaperones:
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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CYCLE Delegate Form

Parent/Guardian Information

Emergency Contacts

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