All forms from each school should be returned together. Each participant (students and adults) must fill out registration form. For more information call Student Leadership Services at (248) 706-0757.
Please type or print legibly:Circle One:StudentAdvisorParentOther______
Name: ______Dietary Requests/Concerns: ______
Address: ______City: ______Zip: ______
Phone: (_____) ______E-mail: ______
School: ______Gender ______Age: ______Grade: ______
Are you currently involved in an SLS Chapter at your school? _____Yes______No
T-Shirt sizeSmallMediumLargeX-LargeXX-LargeXXX-Large
*T-shirts are first come, first serve and are not guaranteed.
Emergency Contact: (Adults too!)
Name: ______Relationship: ______
Home phone: (_____) ______Work / Cell (circle one): (_____) ______
Alternate: ______Relationship: ______
Home phone: (_____) ______Work / Cell (circle one): (_____) ______
Photographs and videos will be taken during the conference to be used for SLS Social Media. May we use your photo/video? Y N
I, ______, being the natural parent/legal guardian of ______, a minor who resides at ______, hereby grant Student Leadership Services, Inc. (SLS), or its designee, the right to transport the above-captioned minor, to any emergency medical or health care facility for immediate treatment and/or consultation, if necessary.
Health History: (please check and date all that apply)
____ Ear Infections____ Chicken Pox ____ Hay Fever ____ Behavior *please describe
____ Rheumatic Fever____ Convulsions ____ Diabetes______
____ German Measles____ Mumps ____ Measles
____ Asthma___Other *please describe
______
Allergies: (please check all that apply)
____ Insect bites ____Penicillin____ Other drugs ______
COSTS:
EARLY Registration: $50 - Includes all conference materials, activities & lunch(payable to Student Leadership Services)
StudentLeadership Service will accept individual or personal checks or school checks.
Regular Registration (after 10/5) is $60; Late Registration (after 10/20) is $75
Participating Chapter Fee: $50 per participatingchapter/group/school for the entire 2017-2018 school year. When you
become a Participating Chapter you receive countless benefits such as discounted/free training rates, scholarships, assemblies,
grants andthe latest prevention research. CONFERENCE REGISTRATION DEADLINE: OCTOBER 23, 2017.
Student Leadership Services, Inc. *1150 Scott Lake Rd. * Waterford, Michigan 48328* Phone: 248-706-0757 * Fax: 248-706-0750