NC YOUTH DEPARTMENT YOUTH REGISTRATION FORM

                                                                                                                         

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    TEMPLE OR COURT NAME                                                                                              NUMBER

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YOUTH DIRECTOR / DIRECTRESS NAME                                                                    TELEPHONE #

ADDRESS                                         CITY                                       STATE                                    ZIP CODE

PLEASE TYPE OR PRINT

            NAME                                                            ADDRESS                              M/F               AGE          T-Shirt Size

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3_________________________        ________________________            _____          ______                _____

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7_________________________        ________________________            _____          ______                _____ 8_________________________        ________________________            _____          ______                _____

9_________________________        ________________________            _____          ______                _____

10_________________________      ________________________            _____          ______                _____

PLEASE RETURN FORM TO:

REGISTRATION FEE $15.00 IN ADVANCE BEFORE MAY 30th $20.00 AFTER MAY 30, 2010 ON-SITE

Dt. Syvia D. Little (90)                                                        

1926 Wheatfield Court

Greensboro, North Carolina 27405 

Isiserette Lakiyah Lee (90)

Gala Day Youth Registra