Saturday, March 23, 2019, 8:30 a.m.. - 3:30 p.m.

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REGISTRATION FULL!! But wait.....Don't go. Please register and we will add you to our waitlist.

Thank you for your interest in attending our conference.

To reserve your seat, please fill out the information below.

Student's First Name *

Student's Last Name *

Student's Email Address *

School Name *

Grade *

Student's Home Address 1 *

Student's Home Address 2

City *

State *

Zip Code *

Student's Cell Phone Number *

T-Shirt Size *

On behalf of Capital One and our Women’s Business Resource Group, we are thrilled to announce registration is now open for the 15th annual Future Leaders Forum for Young Women. We invite you to register for our program which inspires young women and encourages them to develop into the leaders of tomorrow.

About the Future Leaders Forum for Young Women

As in years past, this full-day event welcomes young women in grades 9 through 12 to the Capital One campus, where they will participate in activities designed to inspire, encourage and build their leadership skills. This year’s theme will be “I Am.” Throughout the day, students will enjoy meeting and networking with young women from across the area, hearing from dynamic speakers, and working with mentors to build their leadership skills.

About Capital One

As Capital One continues to grow and diversify, our Shared Values remain constant—Excellence: how we perform as individuals, teams and an organization, and Do the Right Thing: how we interact with each other, our customers and our community. These Values are the foundation on which we’ve built our culture, our business, and our philanthropic program. Supporting our communities brings our corporate Values to life. Through associate engagement, philanthropic partnerships and nonprofit board leadership, we strive to be a meaningful part of the fabric of our communities.

Personal Statement: To help our mentors provide the best experience possible, students should write a brief (1-2 paragraphs) statement about themselves and their goals after high school. *

How did you hear about this event *

Permission Form (to be filled out by parent/guardian)

Emergency Medical Release In the event of an emergency, I, give my permission for Capital One to provide first aid and to transport my child to a medical facility, if necessary. In case of an emergency, if I, or the contact named below, cannot be reached personally, I consent to treatment of my child under the supervision of and as deemed advisable by a licensed physician. I indemnify, release and hold harmless Capital One Financial Corporation; and their affiliated corporations, subsidiaries, affiliates and other related entities; their joint venturers, stockholders, successors, assigns, insureds, officers, directors, agents, representatives, employees, contractors and other personnel, jointly and severally, and any first aid/medical care providers they may engage from any claims related to my child’s participation in the Future Leaders Forum for Young Women; the provision of first aid to, and emergency medical care and treatment of, my child; and including any accident, injury or death arising in connection therewith.

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent address same as student address? *

Yes

No

Street Address *

Address Line 2

City *

State *

Zip Code *

Parent/Guardian Phone Number #1 *

Parent/Guardian Phone Number # 2

Parent/Guardian Email Address *

PLEASE NOTE: A confirmation email will be sent to BOTH the student and parent/guardian's email address.

If I cannot be reached please contact: *

Emergency Contact Phone Number #1 *

Emergency Contact Phone Number #2

Hospital Preference *

Special Medical or Dietary Needs (Including Allergies) *

Parent/Guardian Signature *

clear

Photo Release Capital One Financial Corporation and its affiliates (collectively, “Capital One”) has my permission to use my or my child’s photograph and/or name publically to promote the Future Leaders Forum for Young Women. I understand that the images may be used in print publications, online publications, presentations, websites, social media, and other channels. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use, nor is Capital One obligated in any way to use my or my child’s name and/or likeness.

Parent/Guardian Signature *

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I have attended previously	School Guidance Counselor/Teacher
Family/Friend is a Capital One Associate	Family/Friend attended previously
Girl Scout Leader	- -