2012 NYA Day Registration 1. Default Section 100% of survey complete. Question Title * 1. Please enter your contact information. Name: * Address: * Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Email Address: * Phone Number: * Anyone under the age of 18 must have parental/guardian consent to attend the National Youth Alliance Day. If you are under the age on 18 please fill out the parental/guardian consent form that can be found at www.hdsa.org/nya It must be signed and returned to the National Office on or before May 1, 2012 Question Title * 2. Are you under the age of 18? Yes No Question Title * 3. If you are under the age of 18 will a parent/guardian accompany you? Yes No Question Title * 4. Are you planning to stay for the National Convention? Yes No Question Title * 5. If yes, have you registered for the National Convention? Yes No Please note that registering for the NYA Day DOES NOT register you for the HDSA National Convention. If you have not yet registered please do so at www.hdsa.org/convention Question Title * 6. Including yourself, how many people will attend the Thursday Morning Breakfast? 1 2 3 4 5 I will not attend Question Title * 7. Thursday Night Activity is open only to NYA Members and NYA Alumni. If you are planning on attending please enter your Name. If you are registering yourself and other NYA Members/Alumni please enter their names as well. If you will not attend the evening activity please place an X next to "I will not attend" 1 2 3 4 5 I will not attend Question Title * 8. In order to complete your registration you are required to provide your hotel reservation name and number.Hotel reservations must be made on your own. The program includes a complementary one night hotel stay. If you do not provide this number or it is incorrect you will not receive a complementary night. All scholarship recipients please type in "Scholarship". Done