By submitting this form, you are committing to building a Culture of Health in your community and are entering to win a $2,500 credit towards registration for the 2017 National Youth Summit on Healthy Living. Registration includes: program fees, materials, lodging, and meals. This credit may be used by youth and/or adult chaperones. All participants must be accompanied by a participating adult. Please visit the following link for more information: http://www.nationalyouthsummit.org/healthy-living-conference/

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is the best e-mail address to contact you?

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* 4. What is your role?

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