Keys to Leadership Registration 2013

1. Keys to Leadership 2013 Registration

This is the registration form for your daughter to attend the 6th Annual Keys to Leadership Conference Saturday, March 8 at American University. Please answer every question. Please send your payment of $10.00 to:

Keys to Leadership 2013
Attn: Andraea LaVant
4301 Connecticut Ave. NW, M-2
Washington DC 20008

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* 1. Teen's Name and Last Name:

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* 2. Age:

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* 3. Date of Birth:

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* 4. Address:

Address:

Apartment Number:

City:

State:

ZIP Code:

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* 5. Current School Attending:

Name:

State:

Grade:

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* 6. Are you currently registered as a Girl Scout?

Yes

If yes, please list troop number

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* 7. Mother/Guardian:

Name:

Phone Day:

Phone Evening:

Phone Cell:

e-mail:

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* 8. Father/Guardian:

Name:

Phone Day:

Phone Evening:

Phone Cell:

e-mail:

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* 9. If divorced or legally separated, please indicate the custodial parent(s):

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* 10. Emergency Contact Information:

Name/Relationship:

Phone:

Name/Relationship:

Phone:

33% of survey complete.