LEAP
327 E. 2nd Street,
Suite # 226
Los Angeles, CA 90012
Phone: (213) 485-1422
FAX: (213) 485-0050
Email: leap@leap.org

Nissan Youth Leadership Program

Please complete this registration form.

* indicates a required field

First Name	* M.I.
Last Name	*
Address 1	*
Address 2
City	*
State	-- Select --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *
Zip	*
Phone	* 888-888-8888
Email	*
College
Year in College	Freshman Sophomore Junior Senior
Ethnic Heritage
Generation	1st 2nd 3rd 4th 5th
* How did you hear about this event?	LEAP Mailing/Brochure Conference Committee LEAP E-Newsletter Colleague Website Friend/Family Other If other, please list
*Describe what it means for you to be a leader. (50 words maximum)
*Brief description of what you would like to gain from this program. (50 words maximum)
*Thank you for your registration! Please click on the "submit" button below to complete the process. For more information about the Nissan Youth Leadership Conference, please contact Scott Chan at: (213) 485-1422 x. 4108 or schan@leap.org.