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MINNESOTA YMCA YOUTH IN GOVERNMENT

SPECIAL SESSION
Saturday, September 17, 2011

REGISTRATION FORM
Name:

________________________________________________________________________________________________

Address:

________________________________________________________________________________________________

City:

___________________________________

State: ________ Zip Code: __________________________

Phone:

___________________________________

Grade: ________

Delegation:

_________________________________________________________________________________________________

E-mail Address: _________________________________________________________________________________________________

The Youth in Government Special Session is a one-day event that will be held at Hilton Towers
in Downtown Minneapolis on Saturday, September 17, 2011 @ 1:00 PM 5:00 PM
(REGISTRATION is 12:30 PM).
The Hilton Towers are located at 1001 Marquette Avenue, Minneapolis, MN 55403
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The cost of the YIG Special Session is $15 per delegate (cash, check or cc). Please attach the fee
to this registration (or call with a cc). However, if you register a delegate who has never
participated in a YIG event, your fee is waived and the new delegate registration is FREE!
I, __________________________________
__________________________________(Please
______________(Please Print Name) as a delegate of the Youth in Government program, agree to
adhere to the Code of Conduct during all activities. If my conduct does not exemplify that of a leader in YMCA
Youth in Government, I understand that I will be removed
removed from the session at my own or my parent's expense.

Applicant's Signature:

___________________________________________________
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I, as a parent of a Youth in Government program delegate,

delegate, give my permission for my son or daughter to
attend the YMCA Youth in Government Special
Special Session and further give my permission to the adult(s)
adult(s) in charge
to seek medical treatment for my son or daughter
daughter if he or she becomes ill or is injured.

Parent's/GuardianSignature:_____________________________________________Date:___________________
Parent's/GuardianSignature:_____________________________________________Date:___________________
Emergency Contact, during the YIG Special Session: (Name and contact number)

_________________________________________
________________________________________________
_______________________________________________
______________________________________
PLEASE MAIL or EE-mail this form to the YIG State Office by 4 PM on Friday, September 2, 2011
ATTN: Jamal Riley 1801 University Ave SE Minneapolis, MN 55414 or jamal.riley@ymcampls.org
YIG CONTACT INFORMATION:
Jamal Riley, State Program Director
Orville Lindquist,
Lindquist, State Program Executive

612612-821821-6502(O)
612612-821821-6503 (O)

612612-963963-3223 (C)
612612-850850-8132 (C)