2024 Junior Representative Application
*Junior Representatives should plan to attend Western or Eastern Mini-Seminar with your county: June 18 or June 19th, respectively. Both will have the same program. We encourage you to join with your county program. If you are unable to attend Mini-Seminar, please provide a written note to PDPPS Board Member or office and please plan to attend Fall Training.
County
*
Adams
Allegheny
Bedford
Berks
Blair
Bradford
Bucks
Butler
Cambria
Centre
Chester
Clarion
Clearfield
Clinton
Columbia
Crawford
Cumberland
Dauphin
Delaware
Erie
Fayette
Franklin
Fulton
Huntingdon
Indiana
Jefferson
Juniata
Lancaster
Lawrence
Lebanon
Luzerne
Lycoming
Mercer
Mifflin
Montgomery
Perry
Potter/McKean
Schuylkill
Somerset
Sullivan
SUN Area
Susquehanna
Tioga
Venango
Warren
Washington
Wayne
Westmoreland
Wyoming-Lackawanna
York
Role
*
Darling
Little Miss
Dairy Miss
Dairy Maid
Dairy Ambassador
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Birthday
*
-
Month
-
Day
Year
Date
Age (As of 6/1/2024)
*
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Years in Dairy Promotion program
0
1-3
3-6
6-10
10+
Grade in School for Fall 2024
Mother's Name
*
First Name
Last Name
Father's Name
*
First Name
Last Name
Parents Address (if different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Cell Phone (if different from above)
-
Area Code
Phone Number
What is your connection to the Pennsylvania Dairy Industry?
*
Own Dairy Cattle
Dairy Farmer's Child
Related to Dairy Farmer/Industry
Family member manages/works on a dairy farm
Other
Farm Name
Number owned by applicant
As the Junior Dairy Promoter and Parent/Guardian, I have read the PDPPS Code of Conduct (found on the Member's Only section of the website and in the Dairy Princess Program Handbook), Dress Code and Program Handbook. I will carry out my responsibilities in accordance with the Pennsylvania Dairy Princess & Promotion Services, Inc. policies and I understand that my title may be removed if I do not satisfactorily follow these established standards. I (we), consent that from this day forward Pennsylvania Dairy Princess and Promotion Services, Inc. has full rights to release and publish all photographs of me in which the participant listed above appears in connection with his/her activities in the Pennsylvania Dairy Princess Program without any compensation to us, either now or in the future.
*
I agree
Name of Participant
*
First Name
Last Name
Name of Parent/Guardian completing this application
*
First Name
Last Name
Please state any known allergies to medication, food allergies, or gluten intolerance
*
Please state any medications taken regularly (include doses)
Please list any medical conditions
Please list Family Doctor's (please leave out Dr./Mrs./Mr.) Name, Address, and Phone Number:
Submit
Print Form
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