2026 WV Youth Empowerment Summit Registration

2026 WV Youth Empowerment Summit Registration

This registration must be completed by the adult chaperone for youth attending the Youth Leadership Track. College-aged (18+) attendees can complete the registration individually.
Tell us about yourself:

Other (Staff, Facilitator, Presenter, etc.)
Name

First NameLast Name
Title
Enter your title or "college student" if you are a student.
Organization
Enter your youth organization if representing a youth group or school if not affiliated with a youth group.
Youth Group Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
For chaperones and adult attendees: How many years of prevention experience do you have?
Youth Group Details

Please provide details below for your youth group. Be advised that this summit is developmentally geared for high school and college students (age 15+). Each chaperone may have no more than 10 youth in their group. During the summit, youth will have the opportunity to participate in up to 2 Heritage Farm activities from the list below (click here for more information). For each youth, be sure to select at least 3 preferences.
- Red Tail Racers Zipline
- Talithakoum Challenge Course
- Tour of Museums
- Tour Animal Areas
How many youth are in your group? (no more than 10)
Youth Participants
Describe any dietary or accessibility needs.
Travel Support

Limited funds are available to support travel. Please check the box below if you/your group need travel support.
Travel Support Needed?
Acknowledgments (Youth Group):
Acknowledgments (Individual):
Signature
Should be Empty: