We're excited for you to join us at

Changemakers Unite: 5th-8th Grade Leadership Summit

proudly planned by:

Please complete this information on behalf of your child

We will be providing snacks during the summit, do you have any dietary requirements you'd like to share?

Check if you are any of the following:

I am vegetarianI am veganI have a food allergy (specify below)

Please explain your food allergy here:

What other issue(s) are you interested in?

Contact Information

First Name

Last Name

Legal/Given First Name (if different from above)

We require this name on record for emergency purposes.

We will not use this publicly.

Which name would you like Keshet to use when communicating with you and your family by email and phone?

First Name (Chosen Name)Legal/Given Name

E-mail

E-mail Type

Oganizations hosting the event might want to reach out to you. Check the box below to opt out of outreach emails from these organizations.

Please do not email me.

Mobile Phone

By sharing your phone number you agree to possibly receive calls from the organizations hosting the event. Check the box below if you would not like to receive calls.

Please do not add use my mobile number for outreach.

City

Type out the full name of your city. No abbreviations, please

State/Region

Please use 2-letter abbreviation for US states

Zip Code

Country

Birthdate?

With which of the following groups are you affiliated? Check all that apply

What size t-shirt would you like?

Emergency Contact Information

Full Name

Phone Number

Relationship to You

Parent/Guardian Event

If you are an parent/guardian, interested in taking part of this incredible day, we will have a program starting at 4pm specifically for adults! Join us for a session led by Paya Sample, the visionary Founder and Owner of Pedagogy in Action. Please see her website for more information: https://www.pedagogyinaction.com/home

Yes, I would like to attend!

Your Contact Information

First Name

Last Name

E-mail

E-mail Type

Oganizations hosting the event might want to reach out to you. Check the box below to opt out of outreach emails from these organizations.

Please do not email me.

Mobile Phone

By sharing your phone number you agree to possibly receive calls from the organizations hosting the event. Check the box below if you would not like to receive calls.

Please do not add use my mobile number for outreach.

City

Type out the full name of your city. No abbreviations, please

State/Region

Please use 2-letter abbreviation for US states

Zip Code

Country

Photo Release Agreement

I give Keshet and its program partners* permission to use pictures or videos of me taken at this event

*Keshet's program partners include: LEAD STL, Saul Mirowitz Jewish Community School, GreenSchoolsQuest, and Missouri Voter Protection Coalition

Admin Fields Hidden

FA Marker

Advocacy Day Youth Campaign ID

Advocacy Day Adult Campaign ID

She/Her/Hers	He/Him/His
Ze/Hir/Hirs	They/Them/Theirs
No Pronoun	No Preference
Other

Asexual	Bisexual	Gay
Lesbian	Pansexual	Queer
Straight	Not Listed

Changemakers Unite: 5th-8th Grade Leadership Summit

We're excited for you to join us at

proudly planned by:

Connect with Us!