Welcome to the Tampa Bay
Young Women's Leadership Symposium

Student Registration Form
NAME OF HIGH SCHOOL (Please insert the name of your Student's school)  
     
 
     
Young Woman's Last Name(required)  
     
Young Woman's Age(required)  
     
Young Woman's Grade Level(required)  
     
Parent's/Guardian's First Name(required)  
     
Parent's/Guardian's Last Name(required)  
     
Parent's/Guardian's Email Address(required)  
     
Relationship to Student(Parent, Grandparent, Legal Guardian)  
     
Address(include city, state and zip code)  
     
Work Phone(required)  
     
Home Phone(required)  
     
Cell Phone(required)  
     
Email Address(required)  
     
Please include any
special dietary needs for the young woman(if any)		  
     
Please include any
medical needs for the young woman(if any)		  
If you're human leave this blank:
     
     
   

By completing this online form, I am submitting the registration and authorizing participation for my Young Woman (Student) at the 2013 Young Women's Leadership Symposium in Tampa Bay, FL on March 3, 2013. This acknowledges that as the parent or guardian of Young Woman (Student) attendee, transportation to and from the Symposium will be my sole responsibility. I take full responsibility and waive and release from any liability all Symposium organizers, all Symposium Sponsors, and all parties of the Florida Diversity Council. Student participation in the 2013 Young Women's Leadership Symposium is fully voluntary. I also grant permission for my daughter (or granddaughter, student) to be included in group event photos.

For more details about the 2014 Young Women’s Leadership Symposium, please contact Sammy Wann [email protected]

Thank you

 

PLEASE COMPLETE THE FORM ONLINE by February 15, 2013 - ***THERE IS NO FEE TO PARTICIPATE***