Kansas City Lideres Congreso Registration Form

National Council of La Raza (NCLR)

Líderes Congreso Sponsored by Sprint Friday, January 27, 2006 University of Missouri­Kansas City Co-Host Organizations

LNESC

REGISTRATION FORM 1. PARTICIPANT INFORMATION Full Name:

Mailing Address:

City:

State:

Zip:

Phone Number:

E­mail Address:

IM and Type of Service (AIM, MSN, etc.):

2. PARTICIPANT PROFILE

I am a student:

 YES

 NO

If yes, check one:  High School  College  Other (please explain)

School name:

Class or Graduation year:

If no, please identify your organization/youth program:

If a staff person, your position:

Age:

Major/Career Interests:

Ethnicity (Puerto­Rican, Dominican, Guatemalan, etc.)

Registration deadline: Thursday, January 12, 2006 REGISTRATION: FREE FOR HIGH SCHOOL STUDENTS, $5 FOR COLLEGE STUDENTS AND PROFESSIONALS – PAYABLE IN ADVANCE. FREE (HIGH SCHOOL STUDENT) REGISTRATIONS MAY BE EMAILED TO: Leadership@nclr.org or faxed to (202) 776­1796.

PAID REGISTRATIONS SHOULD BE SUBMITTED ALONG WITH PAYMENT TO: NCLR, Leadership Development, Raul Yzaguirre Building, 1126 16th Street NW, Washington, DC 20036 Thank you for filling out this form!