2008 Fall Youth Conference

For LGBTQ High School Students
and Their Student Allies
November 8, 2008

1 - First Name:

2 - Last Name:

3 - Optional Nickname to put on Name Tag:

4 - Phone WITH AREA CODE:

5 - Email Address:

6 - If you have a meal requirement, such as vegetarian, please describe:

7 - Name of Your School:

8 - Ohio City in which Your School is Located:

9 - Does your school have a GSA (Gay Straight Alliance) or a Diversity Club?
If neither, skip to item 15

If you do have a GSA OR Diversity Club, complete the following:
	10 - Are You a Member?	Yes
	11 - Name of the Club:
	12 - About How Many Attend Meetings?:
	13 - Name of the Advisor:
	14 - Are YOU The Advisor?	Yes
If you do not have a GSA OR Diversity Club, complete the following:
	15 - Would You Like To Have a GSA Club in Your School?	Yes
	If you would, whom should GLSEN Contact?(Name, Area Code and Phone Number)

ALL STUDENTS CONTINUE TO COMPLETE THE FOLLOWING:

16 - Date of Birth MMDDYY:

17 - What is Your Current School Year:

Freshman
Sophomore
Junior
Senior

18 - STUDENTS and ADVISORS Please add comments if you have any: