Student Registration and Parental Consent

HOBY Community Leadership Workshop

Student Name______________________________________________________________

Student Address____________________________________________________________

City and Zip Code__________________________________________________________

Home Phone______________________________________________________________

School Attending___________________________________________________________

The student listed above has been nominated by his/her high school and invited to attend the Hugh O'Brian Youth Leadership Community Leadership Workshop on (DATE) at LOCATION AND ADDRESS) from (TIME) a.m. to (TIME) p.m.

Parent/Guardian Consent:

I give my son/daughter, listed above, permission to attend the Community Leadership Workshop listed above.

_______________________________________________________

Signature of parent/legal guardian

____________________________________

Daytime phone number

__________________________________________________________________

Date