2017 Youth Range Workshop Application
June 18 – 23, 2017 – Texas Tech University Junction Campus – Junction, TX

It is understood that if this application is accepted, a check for $350 must be submitted by May 31, 2017 to cover the applicants meals and lodging, made payable to “TSSRM Youth Activities Committee”. Check will be mailed to Jenny Pluhar PO Box 931 Canyon, TX 79015. Transportation to and from the workshop will be the responsibility of the local sponsoring group, the county agent, agriscience teacher, or advisor of the organization you're representing, or the participant.

First Name
Your answer
Preferred Name (what you like to be called)
Your answer
Last Name
Your answer
Age as of June 18, 2017
Your answer
Date of Birth
MM
/
DD
/
YYYY
School Classification for the '16-'17 school year
Other School Classification
Your answer
Male/Female
Address
Your answer
City
Your answer
State
Zip
Your answer
County
Your answer
Email Address
Your answer
Home Phone
Your answer
Cell Phone (phone of responsible parent or chaperone bringing you to camp)
Your answer
Do you have rangeland plant identification experience? If so, how much?
T-Shirt Size
4-H Club, FFA Chapter, TSCRA, school club, etc. Represented (write N/A if not applicable)
Your answer
Name of Extension Agent, Teacher, or Advisor
Your answer
Email of Extension Agent, Teacher, or Advisor
Your answer
Address of Extension Agent, Teacher, or Advisor
Your answer
City
Your answer
State
Zip
Your answer
Sponsor Group/Organization (this is the group providing funding for you to attend the workshop, if any)
Your answer
Sponsor Group/Organization Representative
Your answer
Email of Sponsor Group/Organization Representative
Your answer
Address of Sponsor Group/Organization
Your answer
City
Your answer
State
Zip
Your answer
Do you have any food allergies or any other health issues we should know about? Explaining clearly (certain foods, severity, etc.) will enable us to make any arrangements or take any precautions to ensure a safe experience for everyone!
Your answer
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