Xi Zeta Omega Chapter Alpha Kappa Alpha Sorority, Incorporated 2011 Girls Rock: Emerging Young Leaders Empowerment

Conference
Saturday, November 12, 2011 Walker-Jones Education Campus 1125 New Jersey Avenue, NW Washington, DC 20001 8:30 am 3:30 pm

GROUP REGISTRATION
CONTACT INFORMATION GROUP LEADER OR COUNSELOR Name: Name of Organization: Address: City, State, Zip: Daytime Phone: Evening Phone: Cell Phone: Email Address:

Number of Girls Being Registered: Names of Girls Being Registered:

Please register online at: http://xzogirlsrockconference.eventbrite.com or return this completed application and waiver form no later than

Friday, October 21, 2011 to:

Alpha Kappa Alpha Sorority, Inc. Xi Zeta Omega Chapter Attention: Girls Rock: EYL Empowerment Conference P.O. Box 56359 Washington, DC 20011 For information - Call (202) 236-8334; or Email: XZOGIRLSROCK@gmail.com * No Group Registration for Parents/Guardians Workshop

Xi Zeta Omega Chapter Alpha Kappa Alpha Sorority, Incorporated 2011 Girls Rock: Emerging Young Leaders Empowerment Conference
Saturday, November 12, 2011 Walker-Jones Education Campus 1125 New Jersey Avenue, NW Washington, DC 20001 8:30 am 3:30 pm

To be completed for each youth participant in group & signed by their parent or guardian

GROUP REGISTRATION: YOUTH PARTICIPANT

PLEASE PRINT OR TYPE Name: T-Shirt Size: S, M, L, XL, XXL (circle one)

School: Address: City, State, Zip:

Age:

Grade: 6, 7, 8 (circle one)

Phone Number:

CONTACT INFORMATION PARENT OR GUARDIAN Parent/Guardian Name: Relationship to Participant: Daytime Phone: Evening Phone: Cell Phone: Email Address:

Signature of Parent/Guardian Approving Participation:

EMERGENCY CONTACT Name: Phone Number:

ADDITIONAL INFORMATION Special Meal Request (Vegetarian, Vegan, etc.:) Youth has special physical/emotional needs? Yes _____ No _____ Food Allergies: If yes, specify: ______________________________________

Please register online at: http://xzogirlsrockconference.eventbrite.com or return this completed application and waiver form (submit both forms for each youth participant) no later than Friday, October 21, 2011 to:
Alpha Kappa Alpha Sorority, Inc. Xi Zeta Omega Chapter Attention: Girls Rock: EYL Empowerment Conference P.O. Box 56359, Washington, DC 20011 For information - Call (202) 236-8334; or Email: XZOGIRLSROCK@gmail.com Return Completed Form and Waiver to Group Leader or Counselor for submission as a group