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USM STUDENTS, PLEASE FILL OUT PART I / NON USM STUDENTS FILL OUT PART II (BELOW)

Please note: Complete and submit only the form appropriate for you. USM students submit the form in Part I, and non USM students submit the form in Part II. If you have any questions, please contact Learn2Lead@hotmail.com

 
 

PART I: USM STUDENTS (each student complete registration)

YOUR CONTACT INFORMATION:

Your name:
Your mailing address:
Your email address:
Your phone number:

Your age:

Your class status:

Campus Involvement Affiliation (check all that apply):
Student Government
Student Organizations (BSO)
Residential Life
Residence Hall Association
Greek Life
Student Athlete
AmeriCorps
Faculty/Staff Advisor
Other

If "Other" please indicate here:

Please list any leadership positions held on campus:

Do you have any dietary restrictions or need any special accommodations? If so, please list here:

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PART II: NON-USM STUDENTS (one registration per institution)

Institution:
Contact Person:
Email:
Phone:
Fax:
How many people are attending from your school? (please note, there is a $10 cost per person):
List of Attendees (please include name, organization and office(s) held:

Do any of your attendees have any dietary restrictions or need any special accommodations? If so, please list here:

Please submit payment ($10 per person) by making out a check payable to "USM Student Senate" and sending it to:

USM Student Senate
Attn: Leadership Development Board
PO Box 9300
Portland, ME 04104-9300

Please note: Registration is NON-refundable

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