YLS Student Registration

June 28th, 2024

Youth Leadership Summit (YLS) is for middle and high school student leaders who want to see and affect change in their community.

Thank you for your interest in the Indiana Black Expo Summer Celebration Youth Leadership Summit (YLS). Here’s what you need to know.

Student Information:

Open only to students entering 6th to 12th grade.
An individual registration form must be filled out for each student signed by a parent or legal guardian.
No outside non-registered guests are permitted during the weekend.
There is absolutely no tobacco, alcohol, or vaping allowed during the weekend.
Students under 18 at the time of registration must also have a parent or legal guardian fill out a “Parental Permission” form.

Step 1 of 3

Youth Group ID Code(Required)

Please provide the Youth Group ID Code your group coordinator gave you.

Student Birth Date

Student Name(Required)

First Middle Last

Student Address(Required)

Street Address Address Line 2 City State ZIP Code

County of residence(Required)

Student Email(Required)

Enter Email Confirm Email

Student Cell Phone(Required)

What t-shirt size does the student wear?(Required)

Does the student have any special dietary requirements.(Required)

Please provide information about attendee dietary needs(Required)

Name of Child's School/Organization?(Required)

Parent or Legal Guardian Name(Required)

First Middle Last

Daytime Phone(Required)

Nighttime Phone(Required)

Parent or Guardian Email(Required)

Enter Email Confirm Email

Emergency Contact Name(Required)

First Middle Last

Emergency Contact Phone(Required)

I agree to all of the provisions set forth in this application, including the, Parent/Guardian Waiver & Release Form.
To review the Parent/Guardian Waiver & Release Form, please click here.

Acceptance of the Parent/Guardian Waiver & Release Form(Required)

I agree to all of the provisions set forth in this application, Parent/Guardian Waiver & Release Form

Signature(Required)

Comments

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