YLS 2010 Pre-Registration Form Survey

2010 Youth Leadership Summit
Changing Your Future, Today

Pre-registration Form
The purpose of the Youth Leadership Summit is to celebrate, support, and encourage youth service and leadership.

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1. Student Information (Please print or type all information)

Student Information (Please print or type all information) First and Last Name:
Home Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:

2. School:

School:

3. Grade:

Grade:

4. Age:

Age:

5. Are you connected to a community organization?

Are you connected to a community organization? Yes

No

6. If yes, what is the name of the organization?

If yes, what is the name of the organization?

7. Organization Contact Person:

Organization Contact Person:

8. Organization Phone Number:

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!

YLS 2010 Pre-Registration Form

1. Default Section

*1. Student Information (Please print or type all information)