Iowa Association of Electric Cooperatives

Student Information Form

Please have completed by April 31, 2019

* Indicates a required field
STUDENT
*  Name as it appears on birth certificate or government-issued ID (must be exact for the airline)
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*  This info is needed in order to purchase airline tickets
*  This info is needed in order to purchase airline tickets
Accepted Formats: Images, Text Files, Word Documents, Excel Documents, PowerPoint Documents, PDFs, Graphic Files
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 If your size is not listed, email Shelly @ syork@iowarec.org
 Leave blank, if you have no land line
ACTIVITIES
PARENTS/GUARDIANS

EMERGENCY CONTACT AND MEDICAL INFORMATION
*  Have this be a person OTHER than a parent
Anxiety/depression/other?:
Asthma/breathing concerns?:
Bleeding concerns?:
Convulsions/seizures?:
Diabetes?:
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 a student is involved in a medical emergency and is unable to explain their current medical state. It will enable the 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.


FORMS

Parent/Guardian Release and Medical Examination

I/We give my/our consent for our son/daughter to participate in the Iowa Youth Tour from June 14, 2019, through June 20, 2019 (with orientation the evening of June 13, 2019) sponsored by the Iowa Association of Electric Cooperatives.

I/We understand that this participation involves travel within and outside Iowa, and that at times my/our son/daughter may be traveling and/or participating in activities without the direct supervision of a chaperone.

I/We authorize and direct the Iowa Association of Electric Cooperatives through their staffs and volunteer chaperones, to direct and supervise my/our son/daughter. I/We further request and authorize, the Iowa Association of Electric Cooperatives, through their staffs and volunteer chaperones, to secure any medical or other emergency services the said staffs and volunteer chaperones in their reasonable discretion may deem necessary or desirable for my/our son/daughter during his/her participation in the Electric Youth Tour.                                                                       

I/We hereby release and agree to hold harmless the Iowa Association of Electric Cooperatives their officers, members, staffs, and associated organizations 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 by my/our son/daughter during his/her participation in the Electric Youth Tour. 

Iowa Youth Tour Insurance

Students are covered by trip insurance from the moment they leave home until they arrive back home after the trip. This insurance will serve as the students’ PRIMARY insurance for the week they 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/We 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 my/our son/daughter 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.


RULES AND SOCIAL MEDIA AGREEMENT

The Rules

Students representing Iowa’s electric cooperatives are expected to have a high standard of behavior, and these rules will be communicated to, and followed by all participants.

1. Safety is our number one priority. You must stay in groups of at least three.

2. Be punctual. We have a very busy schedule and don’t want to hold buses or delay our schedule if we don’t have to

3. Participate in all planned activities. You will not be allowed to leave the group at any time.

4. Wear your name tag at all times.

5. Talking on your cell phone or texting is discouraged during scheduled tour activities, at memorials, monuments and other attractions.

6. You must be in your hotel room at the time designated by the tour director or chaperones. You are not to leave your room after this hour except with special permission of a chaperone. Room checks will be made each night, and wake-up calls will be provided each morning.

7. You will share a room with other Youth Tour participants and will be expected to respect the rights of others. After curfew, you will be expected to stay in your room, be ready for bed and reasonably quiet so others may sleep. You will not be allowed to visit other rooms or have visitors in your room after curfew.

8. You must remain at the hotel at all times except when you are participating in planned activities. You will not be allowed to leave the hotel to visit relatives or friends in the area, go shopping or attend other events individually.

9. Smoking, using other tobacco products, consuming alcoholic beverages or using other drugs is prohibited.

10. Due to the terrorist attacks of Sept. 11, 2001, there is a heightened sense of security in Washington, D.C. You will be required to observe all security rules and govern yourself accordingly.

11. Infraction of these rules governing your conduct will be considered cause for terminating your participation. You will be sent home at your family’s expense.

Social Media Agreement for Iowa Youth Tour Participants

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).

Your parent/guardian and 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.
  • If you have a question about something you want to post, please ask a chaperone. Students who engage in inappropriate use of social media sites, including electronic text, may be required to remove all posts in question from social media sites, be required to show chaperones their social media sites when asked or be sent home at the expense of their parent(s), or be subject to any other actions that may be appropriate or required based on the circumstances.

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.
*
 Print your name.
Draw your signature.

Please have completed by April 31, 2019

Questions? Contact Shelly York at syork@iowarec.org

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