House of Representatives


PAGING REQUEST

**PAGING REQUIRES A 4 NIGHT HOTEL STAY COMMITMENT**

Note: Application only, does not guarantee acceptance
* Indicates Required Fields

STEP 1. Please completely fill, sign, and save this   Adobe Acrobat Document Icon   Page Packet  as FirstnameLastname.pdf. You will upload your saved packet after you completed STEP 2.
STEP 2. Completely fill this application form:
Not sure who your Representative is? CLICK HERE to find out!
Representative: *
First Name of Page: *
 
Last Name of Page: *
 
Address: *
 
City: *
State: * Zip: *
   
Cell Number: *
 
E-mail Address: *
 
Gender: *
 
Are you related to the Representative? *
  If Yes, how are you related?
School: *
 
Grade Level: *
 
Paged Before? *
  If Yes:
Hotel Roommate Pref:

Parent/Guardian Name: *
 
Parent/Guardian Phone#: *
 
Parent/Guardian Email: *
 
Parent/Guardian Name 2:

Parent/Guardian Phone# 2:

Non-Parent Emergency:

Emergency Phone#:

Referral Name 1: *
(Teacher/Minister/Counselor)  
Referral Phone# 1: *
 
Referral Email 1: *
 
Referral Name 2: *
(Teacher/Minister/Counselor)  
Referral Phone# 2: *
 
Referral Email 2: *
 
Service Date 1st Choice: *
 
Service Date 2nd Choice: *
 
Service Date 3rd Choice: *
 
You must agree and check all the boxes below to complete the application for OK House of Representatives Page Program.
   I have read, signed and been informed about the content, requirements, and expectations of the dress code policy
   I have read, signed and been informed about the content, requirements, and expectations of the expectations policy
   I have read, signed and been informed about the content, requirements, and expectations of the Medical Release policy
   I have read, signed and been informed about the content, requirements, and expectations of the Travel Release policy
   By checking this box, I am completing this online Paging application.

STEP 3. Please upload your completed and saved FirstnameLastname.pdf packet here:
(Important! You must complete Step 2 before attaching. If you already attached your packet then make any changes on Step 2, you MUST reattach the packet before submitting.)
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It will take several seconds to send the application. If you do not receive a confirmation email within a few minutes of clicking 'Submit Application' button, please check your spam folder.