10th Annual YIA

10th Annual YIA

Event Registration Form
Event Date: Friday, June 13th

Time: 11:00am - 3:00pm

Location: Justice Thurgood Marshall Amenity Center (1315 Division Street, Baltimore MD 21217)

Rules & Requirements
1. The YIA is open to any Baltimore City & Baltimore County high school & college student (ages 14 - 24)
2. Registration is required to attend!
3. If under 18, this form should be filled by parent/guardian and submitted before the deadline.
Student Information*
Parent/Guardian's Name

First NameLast Name
Parent/ Guardian Email
example@example.com
Parent/ Guardian Phone Number
Please enter a valid phone number.
Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student School
Student Grade Level
What grade are you in or just completed
Which of these issues are you most passionate about?

Healthy & Positive EnvironmentsPreventing Youth Drug AddictionMental HealthYouth Supports & Services
Who should we thank for referring or recommending you?
Is there anything else you would like to share in advance of the conference?
Should be Empty: