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Member Info

COYAC Member Information

Form Instructions: COYAC Member Information. Please complete the questions to the best of your ability. Leave questions blank if not applicable. Fields marked with an "*" are required items. * First and Last Name Age Date of Birth. Month/Day/Year Mailing Address Primary email Primary Phone Cell Phone School Affiliation Name of Parent/ Guardian Relationship to Member Day Phone Evening Phone Email of Parent/Guardian Address (if different from member) Emergency Contact Emergency Phone Alternate Phone Term Start Date Projected End Date Senate District Senator

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