Youth Leadership Program Application Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email(Required) Student Phone Number(Required)State Representative & Senator Date of Birth(Required) MM slash DD slash YYYY Names of Parent(s) or Guardian(s)(Required) Parent/Guardian Phone(Required)Parent/Guardian Email(Required) Name of School you Attend(Required) GPA(Required)Career Goal(Required)School Activities(Required)Please include years of participation, elected positions, special honors, awards and accomplishments. Extracurricular Activities(Required)Community, church or any clubs outside of school. Please include years of participation, elected positions, special honors, awards and accomplishments. Why would you be a good representative for Coast Electric in the Youth Leadership Program?(Required)T-shirt Size(Required) Date Completed(Required) MM slash DD slash YYYY COVID-19 Policy(Required) I acknowledge that I must either be vaccinated against COVID-19 or show proof of a negative COVID test before participating in the trips to Jackson and Washington, D.C.