Participant First Name: Participant Last Name: Participant Age: Parent/Chaperone First Name: Parent/Chaperone Last Name: Street Address: City: State: -- AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming Zip Code: Telephone: Email Address: Participant Email Address: Available to be a Host Home? Yes No Possibly Alumni Status: None Green Blue Red Recommended 1 Day Conference - $45.00 Track: -- Beginning Public Speaking 2 Day Conference - $135.00 Track: -- Days 1 & 2 - Beginning Policy Debate Days 1 & 2 - Beginning Value Debate Days 1 & 2 - Intermediate Policy Debate Days 1 & 2 - Intermediate Value Debate Days 3 & 4 - Introduction to Public Speaking Days 3 & 4 - Intermediate Public Speaking 4 Day Conference - $230.00 Days 1 & 2 Debate Track: -- Beginning Policy Debate Beginning Value Debate Intermediate Policy Debate Intermediate Value Debate Days 3 & 4 Speech Track: -- Introduction to Public Speaking Intermediate Public Speaking Billing Information Payment Method: -- Visa Card Mastercard Mail-in Check (If Credit Card) Name as appears on Card: Card Number: 3-Digit Validation Code (appears on back of card): Expiration Date: Month 01 02 03 04 05 06 07 08 09 10 11 012 Year 2007 2008 2009 2010 2011 2012 2013 2014