Welcome to the Gulf Coast
Young Women's Leadership Symposium

Student Registration Form

Deadline for submission is Monday, March 19, 2018.
Name of School
(Please insert the name of your Student's school)
Young Woman's Last Name (required)  
Young Woman's Age (required)  
Young Woman's Grade Level (required)  
Parent's/Guardian's First Name(required)  
Parent's/Guardian's Last Name (required)  
Parent's/Guardian's Email Address (required)  
Relationship to Student
(Parent, Grandparent, Legal Guardian)
Address (Please include City, State and Zip Code)  
Work Phone (required)  
Home Phone (required)  
Cell Phone (required)  
Email Address (required)  
Enter Your Career Interest (s)  
Please include any special dietary needs for the young woman (if any)  
Please include any medical needs for the young woman (if any)  

By completing this online form, I am submitting the registration and authorizing participation for my Young Woman (Student) at the 2018 Young Women's Leadership Symposium in Houston, TX on March 24, 2018. This acknowledges that as the parent or guardian of Young Woman (Student) attendee, transportation to and from the Symposium will be my sole responsibility. I take full responsibility and waive and release from any liability all Symposium organizers, all Symposium Sponsors, and all parties of the Texas Diversity Council. Student participation in the 2018 Young Women's Leadership Symposium is fully voluntary. I also grant permission for my daughter (or granddaughter, student) to be included in group event photos.


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