Division II Leadership Academy
Registration Form

Midwest/South Central Region
February 6-8, 2009
Indianapolis, Indiana

Name:

First:    Last:    Suffix:
(Enter your name as you would like it to appear on all materials.)

Role:

Student-Athlete
Sport: Please Select Archery Badminton Baseball Basketball Bowling Cross Country Diving Equestrian Fencing Field Hockey Football Golf Gymnastics Ice Hockey Lacrosse Rifle Rowing Rugby Skiing Soccer Softball Squash Swimming Synchronized Swimming Team Handball Tennis Track/Field Volleyball Water Polo Wrestling
Sport: Please Select Archery Badminton Baseball Basketball Bowling Cross Country Diving Equestrian Fencing Field Hockey Football Golf Gymnastics Ice Hockey Lacrosse Rifle Rowing Rugby Skiing Soccer Softball Squash Swimming Synchronized Swimming Team Handball Tennis Track/Field Volleyball Water Polo Wrestling (Multi-sport athletes list 2nd sport here.)

-- or --

Coach/Administrator
Title:

Conference
Affiliation:

Please Select Great Lakes Intercollegiate Athletic Conference Great Lakes Valley Conference Heartland Conference Lone Star Conference Mid-America Intercollegiate Athletics Association Independents

Institution:

Address:

Student-Athletes: Note your institutional residence.
Coaches & Administrators: Note your institutional office.
All: Please do not use a P.O. box address.

City:

State:

Please Select Alaska Alabama Arkansas Arizona California Colorada Conneticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin West Virginia Wyoming

ZIP Code:

Phone:

(format: xxx/xxx-xxxx)

E-mail:

Gender:

Female   Male

Racial or Ethnic Group:

American Indian/Alaskan Native
Asian/Pacific Islander
Latino/Hispanic
African American/Black
Caucasian
International   Please specify:
Other:

T-shirt Size:

Emergency Contact (during conference):

Name:
Relationship:
Phone: (format: xxx/xxx-xxxx)

Student-Athletes ONLY:

Current Academic Class:
First Year
Sophomore
Junior
Senior

Are you a member of your (please check all that apply):
Campus SAAC
Conference SAAC
National SAAC
None of the above

Please verify that the information above is correct before proceeding to the next step.