Registration for Together We Stand: Pasco Youth and Community Summit 2016

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* 1. First Name:

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* 2. Last Name:

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* 3. Which best describes your role:

High School Student (Full Day Registration)

Middle School Student (Full Day Registration)

Elementary School Student (Full Day Registration)

School Principal (Full Day Registration)

Community Partner (Information Booth at Networking Lunch)

Community Partner (Full Day Registration)

Student Services Staff (please specify in comments)

Other (please specify in comments)

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* 4. Please identify the school, group, agency, or business that you represent. (If you are registering as a student or parent, please type the name of the school you represent).

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* 5. Phone Number, including area code:

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* 6. Email Address (will be used to confirm your registration and communicate about details):

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* 7. Mailing Address:

Address:

City:

State:

Zip Code:

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* 8. As a result of my participation in the Together We Stand Summit, I agree to work collaboratively with diverse team members to address community-wide issues related to building resilience and reducing youth violence. I agree to serve as a positive, proactive team member.

Yes

No

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* 9. In your own words, what does it mean to create "safer, more inclusive schools and communities"? What do you see as your role in this process?

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* 10. Will you need any special accommodations at the summit? If so, please describe:

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* 11. Did you attend Together We Stand last year?

Yes

No