REGISTRATION – SUNFLOWER GIRLS STATE 2015 Visit our website at www.ksgirlsstate.org Please type or print clearly. Name _______________________________________________________________________________________________________ Last Name First Middle Mailing Address _______________________________________________________________________________________________ Street City State Zip Code Age____ Year in High School ___________ Phone (____) ___________________ ________________________________ Parent or Guardian _____________________________________________________________________________________________ Home Phone (___) _____________________ Business Phone (____) ______________________ Email Address ___________________ ATTENTION: PRINT YOUR 2013 INFORMATION PACKET AT KSGIRLSSTATE.ORG. Fee Contributed by _____________________________________________________________________________________________ Sponsored by _________________________________________________________________________________________________ Unit No. Location District Unit Contact Person ___________________________________________________________________________________________ Address _____________________________________________________________________________________________________ Street City State Zip Code Home Phone (___) _____________________ Business Phone (____) ______________________ Email Address ___________________ DO YOU HAVE A FAMILY MEMBER CURRENTLY SERVING IN THE ARMED FORCES? NO_____ YES_____ RELATIONSHIP? ________________________________________________________________________________ DO ANY OF THE FOLLOWING APPLY TO YOU? If “yes”, please explain: PHYSICAL HANDICAP NO _______ YES ________________________________________________________ MEDICAL CONDITION NO ________ YES ________________________________________________________ MENTAL CONDITION NO ________ YES ________________________________________________________ EMOTIONAL CONDITION NO ________ YES ________________________________________________________ SCHOOL ATTENDED _____________________________________________________________________________ Signature of School Supt., Principal or Counselor: ________________________________________________________ I, ___________________________________ understand that my daughter is to complete the entire session of Sunflower Girls State. (Signature of Parent or Guardian) Please attach current Picture here. Signature of Applicant: ____________________________________ REGISTRATION FORM MUST BE RETURNED BY MAY 15th TO Janice Stathas 18 S. 80TH Place Kansas City, KS. 66111-3045 Upon completion and submission of this form to the Secretary of Sunflower Girls State, you’re registered and accepted to attend this year’s session. : PRINT YOUR 2015 INFORMATION PACKET. . KSGIRLSSTATE.ORG