Name of Person Applying for Scholarship *

First Name

Last Name

Role of Applicant / Attendee *

Parent

Guardian

k12 Student

College / University Student

Law Student

Professional (Legal)

Professional (Educator)

Professional (Other)

Board of Education Member

Other Elected Official

Non-profit Volunteer / Employee

Other - Not Listed

Phone *

(###)

###

####

I would be willing to attend the conference: *

For the first day only (Thurs, July 17)

For the second day only (Friday, July 18)

For both days (July 17 and 18)