Note: Registration is $125 per person which includes training materials, training guide for use with state associations, workshop completion certificate, lunch on Sat. and Sun. snacks, and transportation to and from NLSC hotel to training site.

Name:
Address: City, State, ZIP:
Home Phone: FAX:
E-mail:
Age: Date of Birth: Sex: <pull down> Male Female
State Office Held:
School: School Address:
City, State, ZIP:
School Phone (area code required):
T-shirt Size: <pull down> Small Medium Large X-Large XX-Large XXX-Large

Student Participant Information

Parents' Names:
Parents' Phone Number (area code required):
Name of Teacher/Adult Accompanying Participant to Conference:
Name of Person to contact in event of an emergency:
Contact person's telephone number (area code required):
Contact person's address:
City, State, ZIP:

Liability/Insurance/Medical Information

If you are attending the National Leadership and Skills Conference, Check here and scroll to the bottom and hit Submit.

Name of person responsible for your medical bills:
Guarantor's relationship to participant:
Guarantor's Social Security #:
Guarantor's employer:
Employers Phone Number:
Employer's address:
City, State, ZIP:
Insurance company: Insurance company address:
City, State, ZIP:
Insurance plan number:
Insurance group number:
Insured ID number:
Family Physician:
Physician's phone number:
Do you have any known allergies? <pull down> Yes No
If so, please list here: