2017 Eastern Oklahoma & Southern Plains Regional Summit Application

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Thank you for your interest in attending the 2017 IAC Eastern Oklahoma & Southern Plains Native Youth in Food & Agriculture Summit! This year's summit will be held November 17th - 19th, 2017 at the Chickasaw Retreat and Conference Center in Sulphur, Oklahoma.

We look forward to receiving your application and learning more about your interest in food and agriculture. Applications will be accepted on a rolling basis until all seats at the event have been filled. We encourage you apply ASAP to be considered for the travel scholarship opportunity.

PLEASE NOTE: Your answers to this document will not be saved, should you leave this web page. You will receive a prompt verifying that your answers have been saved upon complete submission of your application.

For all questions, please contact Kelsey at kelsey@indianaglink.com.

Name *

Please provide your entire name (first, middle, last) as it appears on your government issued identification card. This speeds up the travel booking process.

Age *

Date of Birth *

YYYY

What Tribe are you affiliated with? *

What is your Physical Address? *

Physical Address City *

Physical Address State *

Physical Address Zip Code *

E-mail Address (Please use a personal e-mail address, and not that of a teacher/parent/etc. We will utilize this form of communication the most, so make sure it is an account you'll have access to!) *

Confirm E-mail Address *

Cell Phone Number *

Home Phone Number

Gender *

Adult T-Shirt Size (XS, S, M, etc.) *

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