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YOUTH PARTICIPANT REGISTRATION

What grade will you be in at the time of registration (Fall 2021)?9th Grade 10th Grade8th Grade 11th Grade 12th Grade

Did you attend the 2018 ELCA Youth Gathering in Houston, Texas?NoYes

Special Needs (check all that apply):

I use a wheelchair full time.

I have a sensory processing disability that makes me sensitive to light.

I have limited mobility, but I am able to board a bus with no assistance.

I have a sensory processing disability that makes me sensitive to sound.

For the purpose of Service Learning, I am medically prohibited from handlingcertain food products. For the purpose of Service Learning, I am medically prohibited from beingaround animal allergens.

For the purpose of Service Learning, I am medically prohibited from prolongedexposure to sun or heat.

First Name Last Name

Preferred Name

Email Mobile Phone

Street Address

City State Zip

Gender: Male Female Non-Binary Other

Racial and/or Ethnic Identity: African Decent or Black American Indian, Alaska Native

Asian or Pacific Islander

European American or WhiteArab or Middle Eastern

Multiracial / Multi-ethnic

Latino/a

T-Shirt Size (adult sizes) S M L XL XXL 3XL 4XL

If necessary, use the space provided on the next page to share additional information.

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Emergency Contact NameEmergency Contact RelationshipEmergency Contact Mobile Phone

YOUTH PARTICIPANT REGISTRATION (continued)

AdditionalInformationRelated toSpecial Needs:

Gathering Pre-Events:

Register me for the Multicultural Youth Leadership Event (MYLE) - $190

I will not be attending a Gathering pre-event

Register me for the tAble - $190