Teen Leadership Conference
Your Name (teen attending)
*
First Name
Last Name
Teen's Email
*
example@example.com
Teen's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Teen's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Teen's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Teen's Age (today)
*
Caregiver's name
*
First Name
Last Name
Caregiver's Email
*
example@example.com
Caregiver's Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Email
*
example@example.com
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
If this student has any allergies, needs special accommodations, or if there is anything else we should know, please list it below.
Teen's shirt size
*
Please Select
(adult) XS
(adult) S
(adult) M
(adult) L
(adult) XL
(adult) XXL
(adult) XXXL
Reference Information
Who will recommend you
Reference Name
*
First Name
Last Name
Reference Relationship to you
*
e.g. teacher, mentor, Scout Master, etc.
Reference Email
*
Required, we'll email them a form to fill out.
After you submit this form an automated email will be sent to whomever you listed above.
Registration Fee
Total Owed
How will you pay for the $25 registration fee?
*
Pay ONLINE with this form (PayPal or Credit Card) *PREFERRED OPTION BY KDC*
Check or Cash
Request scholarship assistance.
How would receiving this scholarship benefit your teen leader?
Pay on PayPal or with Credit Card (no PayPal account required)
*
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Description
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