Student's First Name

Student's Last Name

Student's Email

Age

Home Address

Street

City

State

Zip code

Adult Contact 1

Note: Students under the age of 18 must have consent from a parent or legal guardian to take part in the Indiana Senate Page Program. Please include names of both parents if applicable.

First Name

Last Name

Relationship
Select OneMotherFatherOther

If other, please explain:

Phone

Adult Contact 2

Note: Students under the age of 18 must have consent from a parent or legal guardian to take part in the Indiana Senate Page Program. Please include names of both parents if applicable.

First Name

Last Name

Relationship
Select OneMotherFatherOther

If other, please explain:

Phone

Requested Dates to Page

Note: Subject to availability. Please specify the date you wish to page, including both month and day.

Please list other dates you are available for paging
Note: The date above may be full. Please specify other days you are available to page.

Please provide the name of the Senator for whom you wish to page
Note: Please make sure you have provided the correct Senator. We strongly encourage you to page for the Senator representing the district in which you live.

Senator's First Name

Senator's Last Name

Note: If you are unsure which Senator represents you, please use our district lookup tool here: http://district.iga.in.gov/DistrictLookup

Medical Information

Please list medications, allergies or any other relevant medical information so we can ensure your safety during your visit.

Are You Wanting to Page With A Friend?
If so, please provide their first and last name.

Other Comments:
Please use the space below to provide further information for the Indiana Senate Page Program. If you want to page for a Senator from another district, please explain here. Or, if there are days in which you absolutely cannot page, please list them.