Leadership Long Beach


Youth Leadership Long Beach Application
First Name *
Last Name *
Address 1 *
Address 2
City *
State/Province *
Zip *
Phone *
Email *
Emergency Contact Information
Parent/Guardian Name *
Parent/Guardian Relationship *
Parent/Guardian Email *
Parent/Guardian Phone *
Demographic Information
Date of Birth *	// (mm/dd/yyyy)
Which high school do you attend? *
What grade are you entering in fall? *
What are your preferred pronouns? *

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