Part I. Contact Information
Full Name
Organization/Group Name
Address	Apt./Box #
City, State, Zip	,
Phone
Email
Website
Date of Birth
Sex	Male Female
Part II. Student Information (***students only***)
School Name
Classification	Freshman Sophomore Junior Senior Graduate
Degree Attaining	Associates Undergraduate Masters Ph.D. In High School Out of School
Major/Area of Study
Campus Address *college students only
Address 2
City, State, Zip	,
Campus Phone
Part III. Survey Information
a. What is leadership to you? b. Why do you want to be a member of New Light Leadership Coalition? c. Sign me up for the following: Conference Committee Fundraising Committee
Part IV. Members Only Website Access Information
Choose a password to access the members only website. (Your username is your email address)
Password

Choose a Membership Option:

Types of Membership	Dues
Youth Membership (Ages 16 to 25)	$25.00
Associate Membership (Ages 26+)	$50.00
Affiliate Membership (Organizations)	$100.00

(Required) I have read and agree with the membership pledge.

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