Wilkes Lead Appalachia Form - Wilkes Youth Life Development

Wilkes County - Lead Appalachia

Step 1 of 6

16%

Teen Information

Name(Required)

First Last

Address(Required)

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

Date of Birth(Required)

MM slash DD slash YYYY

Gender:

How did you hear about Lead Appalachia?(Required)

Other:

Parent/Legal Guardian Information

Name(Required)

First Last

Phone(Required)

Email(Required)

This email will be used to send all of the required permission forms that will need to be signed and return to Wilkes Youth Life Development BEFORE the event.

Hotel Information

Hotel accommodations are available. Please indicate if you will be utilizing the hotel or staying at home during the week of the conference. *If you will NOT be staying at the hotel, transportation will be your responsibility. Drop-off and pick-up times will be fixed and participants will be required to adhere to these times unless otherwise indicated.

Will you be staying at the hotel?(Required)

Accommodations

Do you require any special accommodations?(Required)

Please indication the accommodations that you need:

Dietary Restrictions(Required)

Please indicate your dietary restrictions:

Emergency Contact Information

Please list TWO emergency contacts (these people must be over the age of 18)(Required)

Provide names, phone number(s) and relationship to the youth of all listed emergency contacts.

Who has permission to pick-up the youth?(Required)

Please list all individuals that has the parent/legal guardian permission to pick-up this youth from the event. **We will not be able to release your teen to anyone that is not listed on this form unless otherwise discussed with the parent/legal guardian.**

Conference Registration Quantity(Required)

Price: $150.00

Quantity

By submitting this form you will be purchasing ONE conference registration. Each teen that will be attending Lead Appalachia needs to submit a separate registration form.

Total

Payment Method(Required)

MasterCard

Visa

Supported Credit Cards: MasterCard, Visa

Card Number Expiration Date Security Code Cardholder Name