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Greater Lansing Legislative Onsite

GLLO Registration Form

Student Name:(Required)

Student Phone

Type of phone

Cell

Home

Parent cell

Student Email

Providing your email permits SSI to send periodic updates unless you opt to unsubscribe. All personal information is used solely by Student Statesmanship Institute and our partner organizations, and will not be released, rented, sold, or otherwise distributed to anyone at any time for any reason.

Parent/Guardian Name:(Required)

Spouse Name:

Primary Phone(Required)

Type of phone(Required)

Cell

Home

Work

Parent/Guardian Secondary Phone

Type of phone

Cell

Home

Work

Parent/Guardian Email(Required)

Providing your email permits SSI to send periodic updates unless you opt to unsubscribe. All personal information is used solely by Student Statesmanship Institute and our partner organizations, and will not be released, rented, sold, or otherwise distributed to anyone at any time for any reason.

Street Address(Required)

Address Line 2

City(Required)

State/Province/Region(Required)

ZIP/Postal Code(Required)

Church Attending

Church City

School/Group Name

Date of Birth (MM/DD/YYYY)(Required)

Biological Gender(Required)

Male

Female

Student grade(Required)

Any food allergies(Required)

Yes

No

Please list your allergies here

Have you attended an SSI program before?

I have previously attended an SSI Onsite or I am an SSI LEAD Alumnus.

Which bills did you debate?

Code of Conduct(Required)

I agree to the GLLO Code of Conduct.

By registering, I acknowledge that I will obey and adhere to SSI staff, South Church staff, and Capitol staff while I am at GLLO, and will approach GLLO with open enthusiasm and a can-do attitude.

Permission and Photo Release(Required)

I agree

As a parent/guardian of the student listed above who is attending the SSI Onsite Program, I do hereby give my permission for his/her attendance and, further, I and my child give SSI permission to use my child’s photograph and/or written comments in promotion of SSI. I do agree to hold SSI harmless and indemnify them for any injury or illness, which may result to my child over the course of the two days. We also agree to abide by SSI behavioral standards, including ACTIVE participation in the program, and attendance in all sessions.

Parent Name

Date

GLLO Registration Fee ($45)

Payment method(Required)

Check

Credit Card

Pay by Check

Please mail check to 4407 W St Joe Hwy, Lansing MI, 48917.

Pay by Credit Card

Credit Card

Card Details

Cardholder Name

Phone

This field is for validation purposes and should be left unchanged.

Contact Us

Thank you so much for your help!
If you need help, please feel free to contact us with any questions or concerns.

Aimee Chauvin
Director of Programs

Email:
Programs@ssionline.org

Phone:
517-321-6233x702

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