BGD Registration Form

Name 

Address 

City 

State/Province      Zip Code 

Country 

Home Phone      Work Phone 

Fax 

Website 

Email address 

Date of Birth      Age   Gender 

Languages Spoken 

Please submit with this application
form the following information:

1. Tell us why you want to be a part of the International Youth Summit.
Please include a paragraph about you (i.e. that could be used as a
biography in the Summit Directory).

2. Are you involved with any community organizations or groups? 
 Yes   No

If yes, name the mission and or vision of the organization
and how you are involved.

3. What is your vision for your community?

Do you have a project or idea about how to make this vision a reality?

4. Are you in need of financial assistance in order to attend this conference?
 Yes   No

If yes, please state whether it would be for a partial or full scholarship and amount.