Name of Parent completing this Form*

Parent's Email*

Parent's Cell Number*

Parent's Street Address*

Parent's City/Town*

Parent's State*

Parent's Zip Code*

Name of Teen interested in serving on Lappin Foundation's Teen Advisory Board*

Teen's Email*

Teen's Cell Number*

Teen Street Address*

Teen City/Town*

Teen State*

Teen Zip Code*

Grade in School as of September 1, 2025*

Name of School*

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