2022Youth Advocacy Tour Registration

2022 Youth Advocacy Tour Registration

Thanks for your interest in joining us as part of our Youth Advocacy Tour. This tour is open to high school youth looking to make a lasting impact in their community. Registration does not guarantee participation as space is limited. We will contact all registrants shortly after registration to confirm participation.

Please note space is limited, register today!

Name (First and Last)*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Cell Phone*

Work/Home Phone

Email*

Age *

Birthdate - Month/Day/Year*

Month, Day, Year

What grade will you be in Fall 2022*

What school do you currently attend*

Please select the Tour Stop you will attend (the location closest to you)*

Portland, Maine | October 1, 2022 Columbus, Ohio | October 9-10, 2022 Detroit, MI | October 22, 2022

Organization/group you are part of (if applicable; enter n/a if you are not affiliated with a specific group)*

e.g. Reality Check, No Limits, SWAT, FCCLA, HOSA, NAACP, Alliance for Healthier Generation, etc.

If you are a member of an organization/group: Who is your primary Coordinator/Advisor?

First Name

Last Name

Coordinator e-mail address

Coordinator Phone Number

In 250 words or less, why would you like to join the TakeDown Tobacco Youth Advocacy Tour?