Name(Required) First Last Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Current Grade(Required)Birthday(Required) Month Day Year Unisex Shirt Size(Required)X SmallSmallMediumLargeX LargeXX LargeAbout YouHobbies & Special Interests:(Required)Please list any public speaking or writing experience.(Required)School/Extracurricular Activities:(Required)Parent/Guardian Contact InformationName(Required) First Last Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Letter to Elected Official(Required)Max. file size: 500 MB. This letter should be at least one page and can be any topic that you deem important. It can be political, personal, religious, or medicinal. It should be thorough and profession. You should also be prepared to discuss this with your chaperone and potentially elected officials in Richmond. Letter of Recommendation(Required)Max. file size: 500 MB. This personal cannot be related to you. This can be from pastor, youth pastor, employer, or anyone in academic authority. VICE Application(Required)Max. file size: 500 MB. This application PDF can be found by clicking on the VICE icon on the Youth Scholarship Program landing page. https://www.virginia.coop/vice then select APPLY TODAY. Save that document and then submit it here. Headshot Image for Publication(Required)Max. file size: 500 MB. Please upload a one image of yourself for printing in the magazine, social media use, and submitting for VICE. This can a profession style image taken on a cell phone or even a senior photo. I verify that I will be able to attend and participate in all four events. Please check the box below:(Required) Legislative Day, Feb 11 | VICE, March 18-21 | Day In the Life of a Lineman, April 6 | Annual Meeting | August 10 In order for students to receive a $1,000 scholarship and a $500 donation to a local charity of their choice, all events must be completed. Consent(Required) I hereby verify the information provided on this form to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature with the permission of a parent or guardian. I also agree that by submitting this form I agree to release Community Electric Cooperative of any liability or responsibility of any injury and allow them to use images taken in media for promotional purposes.Electronic Signature (Main Applicant Full Name)(Required)
