Registration: Youth Advocacy and Leadership Open House

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* 1. Name of youth:

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* 2. Preferred name & pronouns:

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* 3. Birthdate:

Date:

Date

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* 4. Address:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 5. Preferred method of contact:

Phone

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* 6. My adult's name:

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* 7. My adult's address (if different than my own):

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 8. I plan to attend:

In person

Virtually (send me the link)

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* 9. If attending in person, we will be serving pizza. Please let us know if you have any special dietary needs or restrictions.

Vegetarian

Food allergy

Other (please specify)

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* 10. I am interested in attending and participating in advocacy events, sharing my story to educate adults on the challenges youth with mental health challenges face in school and the community. Check all that apply.

Day at the Capitol (meeting with my legislators and sharing my story)

Symposium on Mental Health (sharing my story with educators, professionals and parents)

Other opportunities as they arise

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* 11. I am interested in joining the board.

Yes

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* 12. If yes, I could attend board meetings:

Bi-monthly

Quarterly (4 times per year)