2018 East Texas Rural Electric Youth Seminar

Transcription

1 2018 East Texas Rural Electric Youth Seminar June 25 June 29, 2018 on the East Texas Baptist University (ETBU) campus in Marshall, Texas Applications due Friday, April 20, To qualify please complete all forms including the General Waiver. students must be enrolled as a sophomore, junior or senior in the school year to be eligible. Applicant Information Name: Address: Contact Phone: Street or P.O Box City State Zip Date of Birth: Family/Guardian Information Father/Guardian Name Mother/Guardian Name Parent/Guardian Home Phone # Parent/Guardian Work Phone # Name of Your Electric Provider School Information Name of Your High School Graduation Year Rank in Your Class Grade Average Certification & Agreements I certify that the information in this application is correct to the best of my knowledge and I agree to permit the review of this application by anyone representing HCEC or its appointed review committee and, if selected as a winner, to having my name used in promotions related to ETREYS attendance and possible ETREYS scholarship awards. I am also aware that applications that do not follow the directions, late applications, or incomplete applications will not be considered. Applicant s signature Parent s signature

2 School Extracurricular Activities List high school activities, including leadership positions, organizations, class offices, academic awards, etc.: List civic and other activities: Your goals and aspirations after High School graduation? Letters of Recommendation Provide two (2) letters of recommendation, one of which must be from a high school teacher, principal, or counselor. Please attach with this application. Adult T-SHIRT Size (Circle one) Small Medium Large X-Large 2XL 3XL 4XL RETURN ALL COMPLETED APPLICATIONS BACK TO HOUSTON COUNTY ELECTRIC NO LATER THAN APRIL 20 TH, 2018 (POSTMARKED). PLEASE MAIL THEM TO: HOUSTON COUNTY ELECTRIC ATTENTION: KELBY KOEHLER P.O. BOX 52 CROCKETT, TEXAS 75835

3 Attach Portrait Style Photo Here This photo will be used in the ETREYS Directory so please use a head shot. Please do not staple or tape DELEGATE Name: Nickname: Birth Date: School: Graduation Year: Activities: Interest: HOUSTON COUNTY ELECTRIC COOPERATIVE

4 TO: FROM: Parents and Students Seminar Director GENERAL WAIVER 2018 East Texas Rural Electric Youth Seminar ETREYS During the week of the Youth Seminar, we will be traveling from your sponsoring cooperative to Marshall. This trip will be organized and supervised very thoroughly; however, as we all know, incidents do occur. The form below may be very helpful in the event of an emergency. We must have a permission form from each parent/guardian before any student is allowed to travel. I,, give my permission for (Parent/Guardian) (Student) to attend the East Texas Rural Electric Youth Seminar (ETREYS) from June 25-29, 2018 (inclusive). I, the parent/ guardian, will release our local sponsoring cooperative, chaperones, speakers, and all other ETREYS associates from any liabilities involved in these activities. It is understood that I, the parent/guardian, will stand liable for any damages created by the student. This form will also give ETREYS or its chaperones permission to sign for medical treatment if it becomes necessary for my child. Medical treatment will be administered by the nearest medical facility. EMERGENCY CONTACT NAMES & NUMBERS WHERE YOU / SOMEONE CAN BE REACHED: ( ) ( ) INSURANCE INFORMATION (If you do not have medical insurance, please write NO INSURANCE ) (Insurance Company Name) (Telephone Number) (Group / Policy Number) (Policy Holder s Name) (Policy Holder s Social Security Number) SPECIAL INFORMATION Please list any medical history of your child that might be helpful in the event of an emergency. I have read, understand and am willing to comply with the guidelines set forth in this General Waiver and in the ETREYS Policies. I grant permission for my student s bio sheet to be published in the yearbook. (Parent / Guardian Signature) (Date) NOTE: Applicants must return all forms, including this General Waiver, to their sponsoring Cooperative in order to be considered for the seminar.

5 Student Code of Conduct Student: Please read the following Code of conduct. If you agree and are willing to comply with all of the expectations of the Code of Conduct and ETREYS Camp, please sign at the bottom of the page. Parent/Guardian: Please read the following Code of Conduct. Please sign the bottom of this form to show your intent to support the implementation of this Code of Conduct in regards to your child. As a Delegate attending ETREYS Camp, I agree that: I will participate in all aspects of the camp program and to follow the daily camp schedule. I will conduct myself appropriately at all assemblies and activities. I will be challenged to have fun and participate in Leadership activities. I will display sportsmanship in competitive events. I am representing the Cooperative, and I will conduct myself accordingly. I will show respect towards other campers, chaperones, and staff. I will follow instructions from ANY chaperone, adult supervisor, or camp staff. I will only use the recreation areas at the scheduled times. I will follow the policies given at that area. I will respect the camp property. I will not bring or use any form of tobacco, alcoholic beverages, illegal drugs, or fireworks while at camp. I will abide the dress code for ETREYS camp and wear appropriate clothing at all times. I will not wear inappropriate advertising on clothing, including illegal drugs, alcohol, tobacco, sex, or violence. I will not enter any dorm room(s) that is housing members of the opposite sex. I will be in my assigned dorm room after curfew. I will not participate in any act of violence. I understand that acts of violence will not be tolerated and that firearms and weapons, including knives, are prohibited at leadership camp. Any use of inappropriate language, conduct, or harassment (bullying) is prohibited at leadership camp. Failure to meet with these standards will result in these steps: 1. My Cooperative representative will be notified of your inappropriate conduct. 2. I may be asked to call my parents/guardians and report my conduct not in compliance with these guidelines. 3. At the Chaperone s and/or Camp Director s discretion, this may result in parents/guardians arranging transportation home. 4. Inappropriate conduct will result in forfeiting any leadership points or awards. Student Commitment: I, have read and understand the Code of Conduct above. I agree to abide by it for the safety and enjoyment of myself and of other campers. I understand the consequences of failing to meet these guidelines. Name of Student: Cooperative: Signature of Student: Date: Name of Parent/Guardian: Signature of Parent/Guardian: NOTE: This form MUST BE TURNED IN with the complete application or application will not be considered.