Page Application

Note: Fields marked with an * are required.

Personal Information

First Name: *

Last Name: *

Email Address: *

Age: *

Date of Birth: *

Gender: *

Female

Male

Session Applying For: *

County of Birth: *

Country (ies) in which citizenship is held: *

Social Security Number *

Format: 000-00-0000

Home Address

Street Address: *

City: *

State: * ----Military---- AA AE AP ----States---- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code: *

Phone Number: *

Fax Number: *

Senate Page Program

From what sources have you heard of the Senate Page Program? *

Please list any relatives or friends who have served as Senate Pages.

Name: *

Year: *

Relationship: *

Education

Name of present school: *

Dates of Attendance: *

School Address: *

City: *

State: * ----Military---- AA AE AP ----States---- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code: *

School Phone: *

G.P.A. *

Current class enrollment: *

Former Schools: (list in order, begining with most recent. Please include school address and dates attended) *

Parent/Guardian Information

Name of parent/guardian: *

If guardian, relationship to applicant:

Home Address: *

City: *

State: * ----Military---- AA AE AP ----States---- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code: *

Home Phone: *

Work Phone: *

E-mail: *

Name of parent/guardian: *

If guardian, relationship to applicant:

Home Address: *

City: *

State: * ----Military---- AA AE AP ----States---- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code: *

Home Phone: *

Work Phone: *

E-mail: *

Letters of Recommendation

Letter 1:

Name: *

Address: *

Phone: *

Letter 2:

Name: *

Address: *

Phone: *

Letter 3:

Name: *

Address: *

Phone: *

Other Information

1. What inspired you to apply to the Senate Page Program? What do you expect to gain from the Page experience? *

2. What aspect of the Senate Page Program, e.g., the legislative process or working in Washington, D.C., particularly interests you? How would you intend to take advantage of that aspect if you become a Page? *

3. Describe your interest in any of the activities listed below:

A. Art, Science Clubs, Organizations *

B. Music, Athletics, Debating, Public Speaking *

C. Dramatics, School Publications, Summer Experience (camp, travel) *

D. Dance, Student Government, Jobs (paid or volunteer)/Community Service *

4. Have you ever spent time away from home? Did you attend boarding school, camp, foreign exchange program, gifted and talented summer program or something other? Please explain. *

5. Have you been disciplined by your school administration for any reason in the last two years? If so, please explain. *

6. Have you ever been arrested? If so, for what offense? What was the disposition of the arrest, e.g., conviction, acquittal, dismissal of charges? (Arrest will not necessarily be a bar to acceptance. Factors such as the disposition, and seriousness and nature of the violation will be taken into account.) *

7. List any employment you have had in the last two years, including summer and after-school work. *

8. List any awards or honors you have received in the last two years. *

Policy Notice

NON-DISCRIMINATION: The Senate Page Program does not discriminate on the basis of race, religion, disability, gender, national or ethnic origin in administration of its admission or other policies.