Register for the MICHIGAN TEEN CONFERENCE 2019
June 19 & 20, 2019
Saginaw Valley State University, 7400 Bay Rd, University Center, Saginaw , Michigan 48604

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* 1. Youth Information - Registration Cost $160 each

First Name

Last Name

Age at time of conference

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* 2. Youth Gender

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* 3. Is Youth interested in Campus Tour?

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* 4. How many times has Youth has attended conference?

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* 5. Youth Length of Overnight Stay in the Dorm

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* 6. Chaperone Information - Registration Cost $90

First Name

Last Name

Role/Title

Cell Phone #

Email Address

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* 7. Chaperone Length of Overnight Stay in the Dorm

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* 8. Other Adults/Staff Attending - Registration Cost $160 each

First Name

Last Name

Role/Title

Cell Phone Number

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* 9. Adult Length of Overnight Stay in the Dorm

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* 10. Other Adults/Staff Attending - Registration Cost $160 each

First Name

Last Name

Role/TItle

Cell Phone Number

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* 11. Adult Length of Overnight Stay in the Dorm

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* 12. Other Adults/Staff Attending - Registration Cost $160 each

First Name

Last Name

Role/Title

Cell Phone Number

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* 13. Adult Length of Overnight Stay in the Dorm

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* 14. Contact Person

First Name

Last Name

Role/Title

MDHHS Office or Private Agency Name

Agency Address

City, State, Zip Code

Telephone Number

Contact Person Email Address

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* 15.
IMPORTANT

PRINT THIS FORM to use with your YIT check request

PAYMENT must be made by May 30, 2019

SEND TO MichiganTeenConference@samaritas.org or fax to Kristy Watson at 616-356-5779

PAYMENTS MADE AFTER MAY 30 must include an additional $25 per person

Click SUBMIT RESPONSE to complete this form.