The 84 Youth Power Summit Registration 2023 Question Title * 1. Chapter Name: Question Title * 2. Is this a community organization or school? Community Organization School Other (please specify) Question Title * 3. Sponsoring Organization Question Title * 4. City Question Title * 5. Adult Chaperone Name: Question Title * 6. Adult Chaperone Gender Pronoun Question Title * 7. Adult Chaperone email address: Question Title * 8. Adult Work Phone: Question Title * 9. Adult Cell Phone: Question Title * 10. Are there any dietary needs in your group, including food allergies? Question Title * 11. Do you have any accessibility needs? If yes, please describe. (i.e. ASL interpreters and CART Services, etc.) Bus TransportationWe will be providing regional bus transportation to and from the event from select locations. Please indicate whether your group will use bus transportation if provided from your region.NOTE: Pick-up times may be early morningNOTE: Reimbursement for gas will be considered for those who need handicapped accessible transportation. Please contact ccaminiti@hria.org if needed. Question Title * 12. Do you need a bus pick-up? No Yes Question Title * 13. Youth #1 Information Name Pronouns Age Email Address Question Title * 14. Please submit parent consent form Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Question Title * 15. Please upload proof of vaccination Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Question Title * 16. Youth #2 Information Name Pronouns Age Email Address Question Title * 17. Please submit parent consent form Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Question Title * 18. Please upload proof of vaccination Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Question Title * 19. Youth #3 Information Name Pronouns Age Email Address Question Title * 20. Please upload parent consent form Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Question Title * 21. Please upload proof of vaccination Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Question Title * 22. Youth #4 Information Name Pronouns Age Email Address Question Title * 23. Please upload parent consent form Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Question Title * 24. Please upload proof of vaccination Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Question Title * 25. Youth #5 Information Name Pronouns Age Email Address Question Title * 26. Please upload parent consent form Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Question Title * 27. Please upload proof of vaccination Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Question Title * 28. Youth #6 Information Name Pronouns Age Email Address Question Title * 29. Please upload parent consent form Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Question Title * 30. Please upload proof of vaccination Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Question Title * 31. Youth #7 Information Name Pronouns Age Email Address Waiting ListIf there are more youth and adults who want to Attend the Youth Power Summit beyond the five spaces above, please list the names and information (including age, email and whether they are a “youth” or “adult”). Any additional registration requests from your group will be placed on a waiting list and immediately notified as space becomes available. We will do our best to include everyone who wants to come! Question Title * 32. Please upload parent consent form Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Question Title * 33. Please upload proof of vaccination Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Question Title * 34. Waiting List Youth #1 Information Name Pronouns Age Email Address Question Title * 35. Waiting List Youth #2 Information Name Pronouns Age Email Address Question Title * 36. Please upload parent consent form Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Question Title * 37. Please upload proof of vaccination Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Question Title * 38. Please upload parent consent form Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Consent FormsPlease submit a consent form for each youth attending the event - this was emailed to you and can be found at the84.org. Consent forms should be sent to mduenas@hria.org by Wednesday, December 7, 2022. Question Title * 39. Please upload proof of vaccination Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload signed parent consent forms and proof of vaccination here. You can submit these forms at a later time, but you will not be able to attend the Youth Power Summit without them. Done