2015 Student Leadership Conference

October 1-3 • Pokagon State Park • Angola, IN

STUDENT REGISTRATION FORM

Student applicants: Please complete this form and e-mail it to your state AHPERD office for approval (listed at bottom of form).

State Association:______State Leader Approval (To be completed by state AHPERD):______

Conference fee is $150 (includes room, meals and registration). Check with your state AHPERD association for sponsorship. Midwest District pays for the first two students per state. The next eight are paid by the state AHPERD. Payment is due from the state AHPERD, on or before 1st day of conference.

Student’s Name: ______Gender: M or F______

School Mailing Address:______

CityStateZip

Home Mailing Address: ______

______

CityStateZip

School Phone: ______Home Phone:______

E-mail Address: ______Cell #:______

College/University: ______Major: ______

Year in School: (circle) FreshmanSophomoreJuniorSenior_____

Anticipated Graduation Date:___month______year______

Are you a member of your state association? Yes___ or No___ SHAPE America member? Yes___or No___

Have you attended and/or presented at your state conference? Yes ___ or No___

Have you attended a National Convention? Yes ___ or No___ if so, which one?______

Have you attended your State Student Leadership, the Midwest Leadership or the National Student Leadership Conferences? Yes ___or No___ if so, which one?______

Are you involved in your State AHPERD Student Leadership? Yes ___or No ___What is your role?

______

The conference program will blend our Midwest association mission statement in a variety of sessions including leadership, networking activities, motivational sessions, and fun recreational times. You will engage in leadership training sessions that develop trust, ethics, and professional integritythrough "hands-on" activities.

Note: This conference is for UNDERGRADUATE students. You must be nominated and your application submitted by your state association to attend! See contact information for your state AHPERD office below. Participants are expected to attend the FULL conference.

Contacts:

Midwest District Council for Future Professionals Advisors:
Rhonda Hovatter ()or Julia Tracy ()

Midwest District Executive Director:

Jim Cook ()

937-484-7478 (O) 937-206-9275 (C)

State AHPERD offices:

Please confirm your student registrations ASAP. Registrations are due September 15, 2015 to Jim Cook by e-mail at the address noted above.

Payment from sponsoring organization is due by the 1st day of the conference. Once registration is received via-e-mail (a must!), payment for the student is required. The sponsoring organization or state association will be responsible for the student’s fee if they cancel after the deadline.

Contact information for Midwest State AHPERD offices

ILBob McBride, Executive Director

INKaren Hatch, Executive Director

MIRoger Jackson, Executive Director

OHKaren Holt, Executive Director

WVSue Long, Executive Director

WIKeith Bakken, Executive Director

2015 Student Leadership Conference Registration Form (8/13/15 rev.)