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2. If you would like to participate in Supervisor Federal D. Glover's May 9, 2015, Contra Costa County Youth Summit at Pittsburg High School 1750 Harbor Street, Pittsburg, CA 94565 from 8:00 a.m. - 4:00p.m. please provide the following information.
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6. Contact Information
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12. First Name:*
14. Last Name:*
16. Organization Name:
18. Address:*
20. City:*
22. State:
24. Zip:*
26. Cell Phone Number:
28. Office Phone Number:
30. Email Address:
32. Please list all Social Media profiles
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35. How would you like to be involved with the youth summit? Please check all that apply.*

    1. Participant (Youth)
    2. Present Workshop
    3. Information Table
    4. Volunteer
    5. Lunch Time Activities
    6. Entertainment
    7. Donation/ Raffle Item
    8. Keynote Speaker
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41. Workshop/Entertainment Information
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47. Name of proposed workshop or type of entertainment:
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51. Give a brief description of workshop/entertainment
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55. Upload additional files if available:
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59. If applicable provide link to information:
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63. What is the necessary duration for your workshop?

    1. 1 workshop (45 minutes)
    2. 2 combined workshops (1hour 30 min)
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67. What is the duration of your performance?
    -- Select One --5 minutes10 minute15 minutes
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71. What is the attendance limitation for your workshop:
    -- Select One --No limitation20 students30 students40 students50 students
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75. What do you need provided to perform your service/workshop?

    1. No assistance necessary
    2. Electricity
    3. Laptop
    4. Video Projector
    5. White Board
    6. Markers
    7. Information table for lunchtime
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79. Has there been participation in one of Supervisor Glover's Youth Summits in the past?

    1. Organization
    2. Individual (Presentor/Volunteer)
    3. Participant
    4. No Prior Participation
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83. If applicable what was the prior workshop name/type of entertainment/topic of speech:
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87. Additional Information:
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91. Suggestions for future events:
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95. If you know or any organizations who may be interested please list below. (Name of Organization, Contact Person, Contact Information)
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100. Print Only

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