YOUTH LEADERSHIP CONFERENCE JUNE 2ND-4TH 2023
“DREAM” Determined, Resilient, Eager, Ambitious, Mindset #MLKYLC2023
Registration Form
Please fill this registration form out AND also fill out the Permission Form****
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Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
School
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Grade/Year
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Age
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
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Please enter a valid phone number.
Cell/ Work Number
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Please enter a valid phone number.
Email
*
example@example.com
First and Last Name of Parent(s)
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
Please enter a valid phone number.
Cell/ Work Number
*
Please enter a valid phone number.
Would you want to participate in the Open Talent Show ?
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Yes
No
If so, what is your talent ?
*
Singer
Rapper
Dancer
Drama
Poetry
Other
What is your T-shirt size ?
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Small
Medium
Large
XL
2XL
3XL or Larger
Are you a vegetarian, or do you have diet restrictions or food allergies ?
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Yes
No
If you answered yes, what are your restrictions/ allergies ?
Please explain if you answered yes on the question above.
Do you have any health/medical issues that need to be addressed?
*
Yes
No
If you answered yes, Please Explain :
Please explain if you answered yes on the question above.
Do you have a disability that requires special accommodations ?
*
Yes
No
If you answered yes, Please Explain :
Are you sponsored by MLK Commission ? If so, list name and contact information :
Sponsorship organization
A middle-or high school ? If so, list school name and contact information :
Sponsorship organization
A College or University ? If so, list school name and contact information :
Sponsorship organization
A civic or non-profit organization? If so, list organization name and contact information :
Sponsorship organization
Signature( Student)
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Date
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Month
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Day
Year
Date
Signature(Parent or Guardian) **All youth under 18 will be assigned a chaperone
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Date
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Month
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Day
Year
Date
Signature (Sponsor Organization and Date)
Date
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Month
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Day
Year
Date
Submit
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