Welcome to the Tampa Bay
Young Women's Leadership Symposium

Student Registration Form
*Name of High School  
     
 
     
*Young Woman's Last Name  
     
*Young Woman's Age  
     
*Young Woman's Grade Level  
     
*Young Woman’s Email Address  
     
*Parent's/Guardian's First Name  
     
*Parent's/Guardian's Last Name  
     
*Parent's/Guardian's Email Address  
     
Relationship to Student (Parent, Grandparent, Legal Guardian)  
     
Address (include city, state and zip code)  
     
*Cell Phone  
     
*Home Phone  
     
*Work Phone  
     
Please include any
special dietary needs for the young woman (if any)		  
     
Please include any
medical needs for the young woman (if any)		  
     
*How did you hear about us?  
     
 
If you're human leave this blank:
     
  *Designates required information

By completing this online form, I am submitting the registration and authorizing participation for my Young Woman (Student) at the 2016 Young Women's Leadership Symposium in Tampa Bay, FL on February 27, 2016. 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 2016 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 2016 Young Women’s Leadership Symposium, please contact Ameerah Mukayed

Thank you

 

PLEASE COMPLETE THE FORM ONLINE by February 20, 2016 - ***THERE IS NO FEE TO PARTICIPATE***