Registration Today's Date (MM/DD/YYYY) Full Name (First, Middle, Last) Mailing Address (3 lines available) Personal Email (NOT School Email) Student Phone Number Public Private Home School Name Of School (Public or Private) Mailing Address of School Grade Freshman Sophmore Junior Senior Have you informed your parents about your interest in this program? Note: If selected as a state delegate to the Moose International Youth Awareness Program, parental consent will be needed. It is the students responsibility to inform their parent/guardian of their participation in the Virginia Youth Awareness program. Yes No Do you give your permission of use of my photo on the VMA Youth Awareness website & social media sites? A yes answer gives consent to The Virginia Moose Association & Moose International to use my students name and photograph in publicity concerning the Youth Awareness Program. Yes No What informational session are you going to attend? (Provide date and location)
