Application Form

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Age and Grade Level

(must be 13-18 years old)

School*

Do you have any campaign or public service experience?*

Please Explain your campaign/public service experience

What changes do you think need to take place in your community/ our state?

Local Newspaper

Special Requirements/ Dietary Restrictions*

Parent/Guardian Name*

Email Address*

Day of Emergency Contact

Name

Relationship

Phone