2019 Youth Conference Registration | Illinois Cooperative Council

Student First Name *

Student Last Name *

First name as it should appear on your name badge *

Gender *

Male

Female

Home Address *

City *

State *

ZIP Code *

Email Address *

County *

Phone Number *

School Name *

Year in school (Fall 2019) *

Sophomore

Junior

Senior

Are you an FFA member?

Yes

No

FFA Chapter Name *

FFA Advisor Name *

School Address *

City *

State *

ZIP Code *

FFA Advisor Phone Number *

FFA Advisor Email Address *

Cooperative Membership *

Please list cooperatives of which you and your family are members. A list of cooperatives in Illinois can be found here: http://www.value-added.org/wp-content/uploads/2015/02/IL-coop-directory.pdf

Cooperatives in your Area *

Please list cooperatives in your area, whether your family is a member or not. Cooperatives could include: farm supply co-ops, credit unions, electric co-ops, telephone co-ops, food co-ops, and more. A list of cooperatives in Illinois can be found here: http://www.value-added.org/wp-content/uploads/2015/03/IL-coop-directory.pdf

Dietary Restrictions *

If other, please explain *

Do you have physical conditions or medical needs we should be aware of? If you select "Yes," an ICC board member will contact you for additional details. *

Yes

No

If yes, please explain *

Emergency Contact Name *

Emergency Contact Relationship to Student *

Emergency Contact Phone Number *

Emergency Contact Alternate Phone Number *

Have you attended the youth conference in the past at Southern Illinois University or Western Illinois University? *

Yes

No

"I give permission for the Illinois Cooperative Council and Western Illinois University to use photographs or videos made of me at the 2019 Youth Conference for publicity purposes, including printed materials and online materials, including social media." *

Yes

No

I acknowledge that a $30 registration deposit is required to complete my registration, and that if I attend the conference, it will be returned. If I do not attend the conference and a substitute is not found, I forfeit my registration deposit. *

Yes

No

T-shirt Size *