Texas Youth Leadership Summit Application Form

Texas Youth Leadership Summit Application

Event Date: July 7th - 10th, 2021 SUBMIT APPLICATION BY JUNE 15
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Applicant's

Information
First Name*
Last Name*
Middle Name
Birth Date*

MonthDayYear
Gender*

FemaleMale
Year of Graduation*
Education level entering in the Fall of 2021*
Do you currently belong to...

A College Republican or Conservative OrganizationA High School Republican or Conservative Organization
Address*

Street Address

Street Address Line 2

CityCounty and State

Zip Code
Phone*

Area CodePhone Number
How did you hear about Texas Youth Leadership Summit?

FriendCollege RepublicansCounty ChairTexas Federation of Republican WomenOther
Emergency Contact Name*
Emergency Number*

Area CodePhone Number
Emergency Number #2

Area CodePhone Number
Minor Release Form

**REQUIRED ONLY IF A MINOR (Under 18)
Parent/Legal Guardian**
Relation**
Work Phone**

Area CodePhone Number
Cell Phone**

Area CodePhone Number
Parent /Legal Guardian 2**
Relation 2**
Work Phone 2**

Area CodePhone Number
Cell Phone 2**

Area CodePhone Number
Minor Applicant Release (List anyone, including parents, to whom the underage applicant can be released)**
Email Confirmation

Be certain to enter your email address correctly on the application form to receive application receipt confirmation and for registration link, if accepted.
Contact Email (Receipt of application confirmation and invite with registration links, if chosen, sent here)*
Applicant's Email (If different than Contact Email)
Health Information
It is our policy to contact the parent/ guardian or emergency contact as soon as possible in the event of a serious accident or injury. If the information has changed on the day of registration, please notify staff. Please bring all medication in ORIGINAL CONTAINER or you will not be allowed to keep the medication or vitamins at the summit. No exceptions. All prescriptions must be in that applicant's name and the correct dosage.
Is applicant free from infectious disease or conditions?

YesNo
Are immunications up to date?

YesNo
Date of last tetanus shot
All fileds are required below. If nothing applies, please put "NONE" in the box.
Any activity the applicant should be restricted from?*
Any physical, mental or other condition that would require special attention or medication while at camp?*
List any past medical treatment that would be helpful for us to know.*
List any allergies (ex: bees, peanuts, dairy)*
Any dietary needs that we should know about?*
List all medications, both prescribed and over the counter, all medications will be turned into the health officer except rescue inhalers, bring all medication in original containers.*
Essay Questions

This summit will be limited to 96 applicants. Please answer the following questions which will be used in participant determination.
What form of government does the US have?*
Why do you want to attend a Youth Leadership Summit?*
Payment Information

This application must be submitted no later than May 31. If you are chosen to attend you will be notified via email. In email, you will receive a link for registration and payment options for the $150 summit fee. (covers food, activities, lodging)
If paying with PayPal you will be redirected to PayPal once you hit submit. You can either pay with credit card, or PayPal. There is a $1.50 processing fee for using this option. The remaining balance is due anytime before their week of camp. If you have any questions feel free to contact _______________.
If paying with a check, please send the registration fee as soon as possible. You can pay multiple registration fees with one check. In memo, please put the camper(s) name. The remaing balance is due _____________. If you have any questions feel free to contact ____________________.
Cabin Buddy

List first and second choice. Requests will be considered, not guaranteed.
Cabin Buddy #1
Cabin Buddy #2
Acknowledgements

Please check to acknowledge and agree to these statements.
Signature*

Clear
Electronic Signature*
Please Initial
Should be Empty:

Texas Youth Leadership Summit Application

Information

Minor Release Form

Email Confirmation

Health Information

Essay Questions

Payment Information

Cabin Buddy

Acknowledgements