Fort Hays State University

Leadership on & off the field:
Leadership development for the student athlete
March 27 & 28, 2007

THIS FORM IS TO BE COMPLETED BY COACHES, SPONSORS, OR MENTORS BRINGING STUDENT ATHLETES.

Please take a moment to fill out this application and then click the submit button. Or this application can be printed and mailed to our office; for a printable version click here.

Coach, Sponsor, or Mentor Information:

Name (first, last)
School Name
USD #
School Address (street, city, state, zip)
School Phone Number (area code and number)
Areas newspaper
What Sports Do You Participate In
Please List the names of all sudent atheletes attending the event:

	Name	Grade	Sport	Special Needs
1
2
3
4
5
6
7
8
9
10
11
*If you have more participants, please fill out additional forms.

T-Shirt Sizes Please give us a total number of sizes that you will need available at the event. T-shirts are adult sizes.
Registration Fees
$85 – Early Bird Discount if submitted by March 15- this applies to student athletes, coaches, sponsors, and/or mentors $100 – Late Registration if submitted after March 15- this applies to student athletes, coaches, sponsors, and/or mentors
Payment Options: Please select your method of payment: Direct Bill - Billing Name and Address Check - Payable to Kansas Youth Leadership Academy Please mail check to: KYLA, 213 Picken Hall, 600 Park Street, Hays, KS 67601 Credit Card - Please contact us by phone if paying with a credit card. Policies and Procedures CONFIRMATION After registering you will receive a confirmation packet within 10 days of submitting your application. CANCELLATIONS All cancellations must be received in writing no later than the deadline date for the event (3-15-07). Cancellations will not be accepted after that date and NO refund will be given. PAYMENTS All payments for the event are due on or before the deadline date for the event (3-15-07). A service charge of 1.5% per month will be applied to all past due accounts. The event offers an early bird discount. To receive this amount, the application and form of payment must be postmarked no later than the early bird discount for the event. SPECIAL NEEDS: It is the responsibility of the coaches, sponsor, or mentor to bring any special physical, medical, or behavioral needs to the attention of the director on the application form. This information will assist us in providing a positive experience for your child. For any questions concerning this form or concerns in general, please contact: KYLA 213 Picken Hall 600 Park Street Hays, KS 67601 (785) 628-5399 KYLA@fhsu.edu Thank you for registering!