Question Title

* 1. Name of Group:

Question Title

* 2. Sponsoring Organization/school:

Question Title

* 3. Adult Chaperone:

Question Title

* 4. Adult Chaperone Gender Pronoun

Question Title

* 5. Adult Chaperone email address:

Question Title

* 6. Adult Chaperone work phone number:

Question Title

* 7. Adult Chaperone cell phone number:

Question Title

* 8. Are there any dietary needs in your group, including food allergies?

Bus Transportation
We 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 morning

NOTE: Reimbursement for gas will be considered for those who need handicapped accessible transportation. Please contact ccaminiti@hria.org if needed.

Question Title

* 9. Do you need a bus pick-up?

Question Title

* 10. Youth #1 Information

Question Title

* 11. Youth #2 Information

Question Title

* 12. Youth #3 Information

Question Title

* 13. Youth #4 Information

Question Title

* 14. Youth #5 Information

Question Title

* 15. Youth #6 Information

Question Title

* 16. Youth #7 Information

Waiting List
If 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

* 17. Waiting List Youth #1 Information

Question Title

* 18. Waiting List Youth #2 Information

Consent Forms
Please 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, March 1, 2023.

T