Youth Leadership Weekend Application 2023

Youth Leadership Weekend 2023

Student Name(Required)

First Last

Preferred name if different from first name

Student E-mail Address(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Student Cell Phone

What grade is the student in?(Required)

What school does the student attend?(Required)

What is the students date of birth?(Required)

How old is the student?(Required)

Please list some special interests, talents, or hobbies of the student?(Required)

Name of Students Guardian(Required)

First Last

Home Address of Guardian(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Guardian Primary Phone Number(Required)

Guardian Backup Phone Number

Guardian E-mail Address(Required)

Emergency contact if guardian isn't available(Required)

First Last

Emergency Contact Phone Number(Required)

Please list any allergies, medical conditions, or physical accommodations below. If none, please put N/A.(Required)

Current Medications: Please include epi-pens, inhalers, etc.

Does the student have any special dietary requirements? Example: Vegan(Required)

Yes

Please list the special dietary requirements.(Required)

Student Signature(Required)

Parent Signature(Required)