STUDENT Y Affiliation Form

Please fill out the form below.

*Required Fields
*Check One:
Please make a selection.
*County: A value is required. A value is required.
*School: A value is required. A value is required.
*School Phone Number: A value is required.Invalid format.
*Advisor: A value is required. A value is required.
*Advisor Email: A value is required.Invalid format. A value is required.Invalid format.
*Advisor Cell Phone: A value is required.Invalid format.
*Advisor Planning Period: A value is required.
*Student Y Meeting Day and Time: A value is required.
*Number of Members: A value is required.

Check here if this is the first year this school has affiliated as a Student Y or this school has not affiliated as a Student Y in the past 2 years.

Please list your officers for the 2011-2012 school year:
President:
Vice President:
Secretary:
Treasurer:
Service Chair:
Other:
Note: A confirmation email will be sent to the Advisor’s email address. Please read and follow the instructions in the confirmation email to complete the Student Y Affiliation.