Fields indicated with an asterisk(*) are required.

Participant Information
First Name
*
Last Name
*
Age
*
Member Code(numeric portion only)
*
E-mail
*
Address
*
City
*
State
*
Country
*
Zip
*
Jr Member Cell Phone
*
Is this your first time attending LEAD?
Please Select
T-Shirt Size
*
Mode of transportation
*
(If flying, flight schedule must be e-mailed
or faxed upon completion of this form.)
Select the option(s) that best describe your background.
Do you raise other livestock in addition to cattle?
Do you raise crops in addition to cattle?
Dietary Restrictions:
Please select yes or no if you will need gluten free meal options.
Please list below additional dietary needs staff should be aware of.
Early registration fee is jr_fee for juniors and advisor_fee
for advisors, which includes your lodging and meals starting with dinner
beg_lead_dt dddd through breakfast on end_lead_dt dddd. The early registration deadline is
early_reg_dt mmmm d. After early_reg_dt mmmm d the registration fee for juniors is
late_jr_fee and late_advisor_fee for advisors.
In case of emergency please notify:
Name
Cell Phone
Address
City
State
Country
Zip
If not available please notify:
Name
Cell Phone
Address
City
State
Country
Zip
Please list any medication participant is allergic to
List any existing medical conditions
List any medications participant is taking
List any other existing condition, medical or otherwise, the staff should be aware of
Do you allow Association staff to give your child over-the-counter medication?
Yes No
If yes, please list:
Payment Information


Billing Information

* *

Credit Card Information

Last 3 or 4 digits on back of card.
Clear