Registration for Student Leadership Workshop

Please complete and submit the following registration form. Closer to the beginning of the program, you will receive details regarding meals, timing, a general outline of the week, etc.
PART ONE
* Denotes required field
Name *
Name
Cell Phone Number *
Cell Phone Number
Home Phone
Home Phone
Address *
Address
Parent/Guardian Name 1 *
Parent/Guardian Name 1
Parent Cell Phone 1 *
Parent Cell Phone 1
Parent Other Phone 1
Parent Other Phone 1
Parent Address 1
Parent Address 1
If different from participant
Parent/Guardian Name 2
Parent/Guardian Name 2
Parent Cell Phone 2
Parent Cell Phone 2
Parent Other Phone 2
Parent Other Phone 2
Parent Address 2
Parent Address 2
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Cell Phone *
Emergency Contact Cell Phone
Emergency Contact Other Phone
Emergency Contact Other Phone
Emergency Contact Address
Emergency Contact Address
If none, please write N/A
If none, please write N/A
Please indicate if you will have medication with you and/or need to take it during the day while at camp. If none, please write N/A
If none, please write N/A
If none, please write N/A
PART TWO: Please fill in the following questions. This is not a test of your academic ability to write the best paragraph, but a chance to think over these questions and write from your heart. There are no wrong answers!
I have had experience helping myself or a friend with mental health challenges such as depression or anxiety. *