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GLSEN Youth Summit at Louisa Registration
Event Timing: 9 AM - 4 PM Saturday March 23, 2019 Check In open at 8:30 AM You must be Pre Registered
Event Address: Louisa County High School, 757 Davis Hwy, Mineral, VA 23117
Contact us at Roland Winston at 804-247-3926 or roland.winston@gmail.com
Sharon Joy Varney-Mahieu at varneysj@lcps.k12.va.us
Email address *
First and Last Name *
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What name do you prefer on your name tag?
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What pronouns would you like on your name tag?
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What is your city and county of residence?
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If you are a student, what school do you go to? Please spell out the name.
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Does your school have a Gender and Sexuality Alliance (GSA)?
Please choose which of the following applies to you?
What is your preferred gender identity? (Optional)
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What is your preferred sexual orientation? (Optional)
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What is your preferred racial/ethnic identity? (Optional)
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Please give a phone number at which we can contact you: *
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How old are you? *
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If you are still a student, we require your emergency contact information. Please include name, relationship and phone number for the day of the summit. Emergency contacts must be over the age of 18 and capable of making emergency decisions for the participant. *
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We are here to help all those who have accessibility needs (e.g. vision, hearing, mobility, non-food allergies, etc.). If you have food allergies, vegetarian, vegan, gluten-free, or kosher needs, please let us know as well. Please type "none" if none. *
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Have you attended a GLSEN summit before? * *
How did you hear about this event?
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