EmailMe Form - Kick Butts Day 2018 Registration

Contact Information

Name of group *

Sponsoring organization/school *

Adult chaperone *

First Last

(the person attending the event)

Adult contact address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Adult email *

Adult cell phone *

### - ### - ####

Adult work phone *

### - ### - ####

Extension

What is the best way to contact you? *

Cell phone

Work phone

Email

What is the best time of day to contact you? *

Morning

Afternoon

Evening

Things we should know

Does anyone in your group have special dietary needs or allergies? *

Yes

No

If yes, please explain. We will do our best to accommodate your needs.

Does anyone in your group require specific physical accommodations? *

Yes

No

If yes, please explain. We will do our best to meet your needs.

Bus Transportation

Please indicate whether your group will use bus transportation if provided from your region.

*Please note: Pick-up times may be early morning

If provided, will your group use bus transportation? *

Yes

No

What is your preferred bus pick-up location? *Please provide a specific address.

Renewal

Would you like to renew your Chapter for the 2018-2019 year? *

Yes

No

Maybe

If yes, is your contact information still the same? *

Yes

I don't wish to renew.

No

Participants:

Each group is guaranteed space for 6 people to attend, one of which must be an adult chaperone. However, we anticipate that there will be additional room to accommodate more people from each group, so we encourage you to put people on the wait list if there are more than 6 people from your group that want to participate in Kick Butts Day.

If you do not yet know the names of the youth who will attend, please let us know the number of youth you expect to come in the comment box at the bottom of the page.

Note: A copy of signed consent form must be submitted for each youth participant.

Participant Information

Youth or Adult

Participant 1: Name

First Last

Participant 1: Email

Participant 1: Age

Participant 1: Grade

Participant 1: Gender Pronoun

Participant 1: Other Gender Pronoun

Youth or Adult

Participant 2: Name

First Last

Participant 2: Email

Participant 2: Age

Participant 2: Grade

Participant 2: Gender Pronoun

Participant 2: Other Gender Pronoun

Youth or Adult

Participant 3: Name

First Last

Participant 3: Email

Participant 3: Age

Participant 3: Grade

Participant 3: Gender Pronoun

Participant 3: Other Gender Pronoun

Youth or Adult

Participant 4: Name

First Last

Participant 4: Email

Participant 4: Age

Participant 4: Grade

Participant 4: Gender Pronoun

Participant 4: Other Gender Pronoun

Youth or Adult

Participant 5: Name

First Last

Participant 5: Email

Participant 5: Age

Participant 5: Grade

Participant 5: Gender Pronoun

Participant 5: Other Gender Pronoun

Youth or Adult

Participant 6: Name

First Last

Participant 6: Email

Participant 6: Age

Participant 6: Grade

Participant 6: Gender Pronoun

Participant 6: Other Gender Pronoun

Waiting List

If there are more youth and adults who want to attend Kick Butts Day beyond the six spaces above, please list the names and information below. Any additional registration requests from your group will be placed on a waiting list and immediately notified as space becomes available. We will do our best to include everyone who wants to come!

Waiting List 1: Youth or Adult

Waiting List 1: Name

First Last

Waiting List 1: Email

Waiting List 1: Age

Waiting List 1: Grade

Waiting List 1: Gender Pronoun

Waiting List 1: Other Gender Pronoun

Waiting List 2: Youth or Adult

Waiting List 2: Name

First Last

Waiting List 2: Email

Waiting List 2: Age

Waiting List 2: Grade

Waiting List 2: Gender Pronoun

Waiting List 2: Other Gender Pronoun

Waiting List 3: Youth or Adult

Waiting List 3: Name

First Last

Waiting List 3: Email

Waiting List 3: Age

Waiting List 3: Grade

Waiting List 3: Gender Pronoun

Waiting List 3: Other Gender Pronoun

Legislative Visit Info

We want to make sure Chapters know exactly what's going to be happening this year. Please provide 3 times between February 15-March 10 that you would be able to speak with your 84 staff representative about the expectations surrounding Kick Butts Day and the legislative visits. We'll be able to provide you detailed information that could benefit your youth.

Available dates: *

Comments: