YLS 2010 Pre-Registration Form 1. Default Section 2010 Youth Leadership SummitChanging Your Future, TodayPre-registration FormThe purpose of the Youth Leadership Summit is to celebrate, support, and encourage youth service and leadership. Question Title * 1. Student Information (Please print or type all information) First and Last Name: * Home 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/Postal Code: Email Address: * Phone Number: Question Title * 2. School: Question Title * 3. Grade: Question Title * 4. Age: Question Title * 5. Are you connected to a community organization? Yes No Question Title * 6. If yes, what is the name of the organization? Question Title * 7. Organization Contact Person: Question Title * 8. Organization Phone Number: Media Information: Media will be present at the Youth Leadership Summit. Photographs or other media may be used for North Central Massachusetts Youth Leadership Summit’s promotional materials and for their website. Thank you for pre-registering for the 2010 Annual Youth Summit. Students who have pre-registered will have first choice of workshops when they arrive on April 23rd at 9:00am. Conference staff will do their best to place students in their first workshop choices.We look forward to seeing you in April! Done
