Orange County NC Website
Browse       Search
7 <br /> AT ON <br /> GATHERI G <br /> -f'O r <br /> -db YOUTIR- ORGAN MING <br /> April 4th-7th <br /> San Antonio, TX <br /> REGISTRATION <br /> Please complete one set of forms per registrant. Please print clearly. <br /> Return to: YouthAction,,PO Box 12372, Albuquerque, NM 87195 or fax to 505-873-3245. <br /> Got questions? Call us at 505-873-3345. <br /> -- Early Registration/Scholarship Deadline: March 1.5th -- <br /> - Late Registration Deadline: March 2e — <br /> --Travel Day to National Gathering: April 4 I _ <br /> t <br /> --Sessions Begin on April 5th_at 9:00 am &End on April 71h at 1:00 pm— <br /> *Please complete all sections for your registration to be accepted. Space is limited, <br /> so please return this form as quickly as possible to ensure your registration* <br /> I. PARTICIPANT INFORMATION ' <br /> Name: First - Last <br /> Age: Gender: (m/f/t) Organization: <br /> Send mail to my (please circle one): home or organization <br /> Address: , <br /> City: State: Zip: ` <br /> Work phone:(____) - Home phone:(__) <br /> Fax:(_) E-mail: <br /> Can we give your contact information to others (for example: a contact list for everyone at <br /> the National Gathering)? 0 Yes No <br /> Can we use your photo in publicity and follow-up materials? = Yes ❑ No <br /> Mail to: YouthAction PO Box 12372,Albuquerque,NM 37195 or fax 505-873-3245 <br /> Got Questions?Call us at 505-873-3345 <br />