2025 Youth Tour Chaperone Information Request

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This field is for validation purposes and should be left unchanged.

PERSONAL DATA

Name:(Required)

First Middle Last Suffix

Preferred Name for Name tag:(Required)

Driver's License or Official State Identification(Required)

We need a scan or digital photograph of your driver's license or official state identification. As of May 7, 2025, anyone who boards a domestic flight or enters a federal building will either need a REAL ID driver’s license (DL) or Identification Card (ID).

Upload a scan or digital photograph of your identification here:

Max. file size: 256 MB.

Social Security Number(Required)

This is required to submit for a tour of the White House and the FBI Headquarters. While we are not guaranteed that these tours will be accepted, this information is required to submit a request. This information will be kept confidential to only the Arkansas Youth Tour Director and Federal entities requesting it.

Birthdate (mm/dd/yyyy):(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Mobile Phone:(Required)

Email Address:(Required)

U.S. Citizen:(Required)

Yes

Gender:(Required)

Male

Female

Country of birth:(Required)

Emergency Contact:(Required)

Phone number for emergency contact:(Required)

Email Address for emergency contact:(Required)

T-Shirt Size:(Required)

Ladies' Cut Polo-Shirt Size:

(For female students only. Male students will receive polo shirt size according to T-shirt size)

MEALS

The Electric Cooperatives of Arkansas will cover all expenses for meals, lodging and tours. Some group meals will be buffets, while others will allow participants to select their own options.

Specify any food allergies or dietary restrictions (If none, write "N/A".)(Required)

NRECA REGISTRATION & MEDICAL RELEASE

The National Rural Electric Cooperative Association's (NRECA) registration and medical release form must be completed. All NRECA rules and policies also pertain to Arkansas Electric Cooperatives, Inc. (AECI).

Please visit this link to complete the registration and medical release for the National Rural Electric Cooperative Association: NRECA Registration & Medical Release.

Signature agreeing to NRECA's Registration and Medical Release(Required)

DESIGNATION OF BENEFICIARY

Arkansas Electric Cooperatives, Inc. purchases accident insurance coverage for each Youth Tour chaperone that is effective from the time the participant leaves his/her residence to participate in the tour until he/she returns to Little Rock. This form names a beneficiary for the $10,000 benefit.

Name of Chaperone:(Required)

First Last

Street/Rural Route/PO Box(Required)

Street Address Address Line 2 City State ZIP Code

I do hereby designate:

Name of Beneficiary:(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

As my insurance beneficiary during the 2026 Electric Cooperatives of Arkansas Youth Tour during the week of June 13-19, 2026.

I understand that this insurance, purchased by Arkansas Electric Cooperatives, Inc. will be in effect from the time I leave Little Rock, Arkansas, on said Youth Tour until the time I return to Little Rock, Arkansas, from Washington, D.C., on said Youth Tour.

Signature(Required)