Student Registration

Asian Youth Leadership Summit and Asia Resources and Cultural Fair SATURDAY, OCTOBER 6, 2012

NAME OF MIDDLE OR HIGH SCHOOL*
(Please insert the name of your Student's school)
Student Name*
First Last
Student Age*
Please enter a number greater than or equal to 1.
Student Grade Level*
Please enter a number from 6 to 12.
Parent/Guardian Name*
First Last
Parent/Guardian Email*
Parent/Guardian Relationship to Student*
(Parent, Grandparent, Legal Guardian)
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Work Phone*
Cell Phone*
Does the student have any special dietary needs?*
- Yes
- No
If they have special dietary needs, what are they?*
Does the Student have any medical issues that the Summit Organizers should be made aware?*
- Yes
- No
If they have medical issues, what are they?*
By selecting this box, I am submitting the registration and authorizing participation for my son/daughter/grandson/granddaughter at the Asian Youth Leadership Summit in San Antonio, TX on Saturday, October 6, 2012. This acknowledges that as the parent or guardian of the student attendee, transportation to and from the Summit will be my sole responsibility. I take full responsibility and waive and release from any liability all Summit organizers, all Summit Sponsors, and all parties of the Texas Diversity Council. Student participation in the Asian Youth Leadership Summit is fully voluntary. I also grant permission for my student attendee to be included in group event photos.*
- Agree

Asian Summit