5th Anniversary Annual Anti-Bullying/Gay-Straight Alliance Summit Registration Form

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Saturday, October 29, 2016; 10:00 AM - 3:30 PM
Polytech High School- Adult Education/Conference Center
823 Walnut Shade Rd, Woodside, DE 19980
Registration must be completed by October 21st, 2016

First Name *

Last Name *

What are your preferred gender pronouns?

Male pronouns (he, his, him)

Female pronouns (she, her, hers)

Gender neutral pronouns (they, their, theirs/ze, hir, hirs/etc.)

Other:

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E-mail of individual registering *

School Name *

PARENTAL/GUARDIAN PERMISSION FOR FIELD TRIP

If you are in need of transportation to and from the conference, please indicate that you need transportation and which stop you will get on the bus. You must complete the Parental Permission Form and provide it upon boarding the bus.

Sussex East- Cape Henlopen High School- 1250 Kings Highway, Lewes

Sussex East- Sussex Central High School 26026 Patriots Way, Georgetown

Sussex East- Milford High School 1019 North Walnut St., Milford

Sussex West- Laurel High School 1133 South Central Avenue, Laurel

Sussex West- Seaford High School, 390 North Market Street Extended, Seaford

Sussex West- Woodbridge High School 14712 Woodbridge Road, Greenwood

Sussex West- Lake Forest High School 5423 Killens Pond Road, Felton

NCC 1- Mount Pleasant High School 5201 Washington St. Extension, Wilmington

NCC 1- Howard High School of Technology 401 E 12th St., Wilmington

NCC 1- William Penn High School 713 E Basin Rd., New Castle

NCC 1- Middletown High School 120 Silver Lake Road, Middletown

NCC 2- Conrad School of Science 201 Jackson Ave., Wilmington

NCC 2- St. Thomas Episcopal Church, 276 S. College Ave., Newark

NCC 2- Glasgow Safeway 2400 People's Plaza, Newark

NCC 2- Dover High School One Pat Lynn Dr., Dover

Workshop Options

GSA Planning and Sustainability

Avoiding Bullying:Digital Media Safety - Social Media and APPS

What About the Parents? (*Parents Only)

Healthy Relationships

Gender Identity: Beyond the Binary

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Please note any dietary restrictions you may have, including allergies.

Emergency Contact Information

Name *

Phone Number

Parental/Guardian Permission Form

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