Full Name *

Age *

Race/Ethnicity (Optional)

Phone Number *

E-Mail *

Parent’s Email *

School Name/Current Grade *

City of Residence *

Are you a member of any youth organization? If so, which one(s)? *

Please list 3 issues that matter to you (Examples: Self-Esteem, Healthy Living, Preparing for College). (Optional)

Request a song you want to hear at “Girl Code.” We will try to play everyone’s request! (Optional)

Did you attend last year’s “Girl Code” conference?

1 + 3 = ?Please prove that you are human by solving the equation *