Iowa Association of Electric Cooperatives

Youth Tour Chaperone Information Form

* Indicates a required field
*  Name as it appears on birth certificate or government-issued ID (must be exact for the airline)
*  This info is needed in order to purchase airline tickets
*  This info is needed in order to purchase airline tickets
 If your size is not listed, email Shelly @
Asthma/breathing concerns?:
Bleeding concerns?:
Heart murmur/heart disease?:
High blood pressure?:
Implant devices?:
Muscles/bone concerns?:
 If so, please bring brace/splints/wraps
Females: Pregnancy concerns?:
Bladder concerns?:
Recent surgeries?:
Sinus or ear concerns?:
Sleeping disorders?:
Stomach or GI concerns?:
Vision/hearing impairments?:
 If yes, please bring glasses/contacts?

We are asking for this information in case you are is involved in a medical emergency and you are unable to explain your current medical state. It will enable the Iowa Youth Tour team to pass the information it contains onto a doctor or hospital looking after you.

The information that is provided is confidential and will only be used in case of an emergency. If there is medical information that should be supplied but that you wish to remain confidential from the Youth Tour team, you are asked to submit it in a sealed envelope. It can then be handed over unopened to any medical practitioner.

Please note that if relevant information is not given on this form or in an attached envelope it is assumed that you fully accept responsibility for any risks incurred.

We have also asked you to provide information about your next of kin so that if you are involved in a medical emergency that person can be contacted.

The information that you give will be held in a secure file by the Youth Tour leader until the completion of the Youth Tour. It will be securely destroyed at the end of the trip.

Please note: The information that you give will be used by Youth Tour staff on a need to know basis only.


Release and Medical Examination

I understand that this participation involves travel within and outside Iowa.

I hereby release and agree to hold harmless the Iowa Association of Electric Cooperatives their officers, members, staffs, and associated organizations (including NRECA) together with their heirs, successors, or assigns from any and all causes of action, claims, damages, costs, expenses, compensation, personal injury, property loss, or any other loss or injury related to participation in the Electric Cooperative Youth Tour. 

Iowa Youth Tour Insurance

You are covered by trip insurance from the moment you leave home until you arrive back home after the trip. This insurance will serve as the your PRIMARY insurance for the week you are on Youth Tour. On the form, because there is a life insurance portion to the insurance, it is necessary for you to give your full name and the full name of your beneficiary.

Please indicate below your insurance beneficiary during the 2019 Iowa Youth Tour.

Photo Release

I hereby grant permission to the Iowa Association of Electric Cooperatives, Living with Energy in Iowa magazine and our local electric cooperative to use photographs, likenesses, and/or videotape images of me in newspapers, newsletters, magazines, videotapes, radio/television broadcasts, and/or Internet websites for publicity purposes related to the 2019 Iowa Electric Cooperatives’ Youth Tour of Washington, D.C.


Social Media Agreement 

Social media, such as Facebook, Twitter, Instagram, Snapchat, YouTube, personal texting, and others, are powerful tools of communication that can have significant impact on your personal reputation as well as the reputations of the cooperative you are representing, the Iowa Association of Electric Cooperative (IAEC) and the National Rural Electric Cooperative Association (NRECA).

You must read and sign this contract acknowledging personal responsibility to use social media responsibly as a cooperative representative, and a representative of IAEC on the NRECA Youth Tour. Please adhere to the following rules and guidelines when posting on Social Media sites while on Youth Tour or thereafter concerning Youth Tour.

  • Think twice before posting. Privacy does not exist in the world of social media. Even if you think the information will disappear after a few hours, an image, with your name attached, can last a lifetime. Consider what could happen if a post becomes widely known and how that may reflect on your reputation, the reputation of your family and friends, the reputation of your cooperative, IAEC and NRECA. Moreover, the information you place online could jeopardize your future when applying to college or for a job for years after YouthTour.
  • Always be authentic. Be honest about your identity. If you post personally or use a Youth Tour hashtag, make sure you are being a positive representative of your cooperative, IAEC and NRECA YouthTour.
  • When posting on social media while on Youth Tour, you will not be disrespectful, disingenuous, inappropriate oroffensive.
  • Never pretend to be someone else when you post personally or as a Youth Tour representative.
  • Be respectful and thoughtful. Youth Tour participants are committed to showing respect and dignity for all people and to the civil and thoughtful discussion of opposing ideas. Treat others the way you would like them to treat you on social mediasites.
  • Know the rules. Become familiar with the terms of service and policies of the social media sites and networks in which you participate, and the appropriate code of ethics required for responsible online communications.

These guidelines and rules are non-negotiable and the consequences are dependent on the degree of misuse of social media.

 Print your name.
Draw your signature.

Iowa's locally owned electric cooperatives are committed to providing safe, reliable, affordable & environmentally responsible power to 650,000 Iowans.

© 2019 IAEC. All rights reserved.