1st ANNUAL YOUTH SUMMIT
September 24, 2005
The Carolina Theater
309 West Morgan Street
Durham, NC 27701

REGISTRATION


Workshops * Motivational Speeches * Free Prizes* Concert

First Name:
Last Name:
Address:
City:
State:
Zip:
Phone Number:
Student's E-Mail:
Parent/Guardian E-Mail:
Name of High School:
Freshman / Sophomore / Junior / Senior
Date of Birth:
Name of Parent/Guardian:

I hereby grant permission for my child to attend:
Yes          No