Honorary Page Program Form - House Of Representatives - 2017


2017 House of Representatives
Honorary Page Program
Student Name: _____________________________________________________________
Address: _________________________________ City: ________________Zip:_________
Home Phone: _____________________
Age: _________ Grade: ____________
School Name: __________________________________ City: ________________________
Activities, Interests, Clubs, Organizations: ________________________________________
Parent(s)/Guardian Name: ____________________________________________________
Daytime Phone: _____________________
Evening Phone: ______________________
Cell Phone: _____________________ E-mail: ____________________________________
Emergency Contact: Name: ___________________________________________________
Relationship: __________________
Phone: ___________________
Dates preferred for Capitol Visit: [Monday-Thursday in odd-numbered years; Monday-Friday
in even-numbered years.]
Choice: ___________ 2
Choice: ___________ 3
Choice: ____________
Please carefully check your school calendar, family calendar, and athletic/activity
schedules as the page spots fill quickly and changes to your day might not be possible
to accommodate.
Sponsoring (your local) Representative: __________________________________________
If you are not sure who your state representative is, go to the Oregon Legislature website to
find the link . . .
Include with your application, a separate written or typed statement addressing why
you are interested in becoming an honorary page for the Oregon House of
Representatives. Include in your statement what two things you would like to learn
from your experience as an honorary page for the House.


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