164th District Youth Legislative Council 2025 Application

Rep. Gina H. Curry 164^th District / Delaware County

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164th District Youth Legislative Council 2025 Application

Please enter your information below and click Submit to apply.

YOUTH PARTICIPANT INFORMATION

Youth Participant Name *

Preferred Name

Pronouns

Date of Birth *

Grade Level *

9th 10th 11th 12th

School *

Home Address *

Phone number *

Email *

Race/Nationality

Food Allergies

Any health concerns that we should be aware of

PARENT/GUARDIAN INFORMATION

Full Name:* First Name:*

Last Name:*

Email Address: *Email: *

Address: *

City: *

State: *

Zip Code: *

Phone Number: *Phone: *

Emergency Contact Name *

Emergency Contact Phone number *

PARENTAL PERMISSION

By submitting this form, I give permission for my child to participate in the 164th District Youth Legislative Council. *

Agree Disagree

YOUTH COMMITMENT

By submitting this form, I commit to participate fully in the 164th District Youth Legislative Council by attending regularly, respecting others, and by abiding by the rules of the 2025 Youth Legislative Council. *

Agree Disagree

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Contact Rep. Gina H. Curry

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