Requirements for Regional Representatives

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Please complete this form once for each school in your region. If a school does not communicate the information leave that field blank.

Your Name

First Name
Last Name
Region
School
Is this LSRG Currently Active?
YES, LSRG is active
YES, but is still growing/forming
NO, but LSRG is wanting to start back up or is being formed
NO, LSRG has become inactive
LSRG Website
Estimated Size of LSRG
Has your school participated in any advocacy events in the past year?
Yes
No
If you answered yes above please explain
LSRG President/Student Leader
LSRG Student President Name:

First Name
Last Name
Email
Phone
Area CodePhone Number
LSRG Advisor
LSRG Faculty Adviser Name:

First Name
Last Name
Email
Phone
Area CodePhone Number
LSRG Historian & Advocacy Rep
LSRG Historian

First Name
Last Name
Historian Email
Historian Phone
Area CodePhone Number
LSRG Advocacy Rep

First Name
Last Name
Advocacy Rep Email
Advocacy Rep Phone
Area CodePhone Number
If there is any additional information or if there are updates to previously submitted information please note it here:

REGIONAL REPRESENTATIVES – FIRST TASK