Registration Form
For: Introduce a Girl to Engineering Day (GIRLS ONLY EVENT)
Date and Time: 2/24/2018 From 11:45:00 AM to 4:45:00 PM
Cost: $15.00

STUDENT INFORMATION PARENTAL INFORMATION
First Name* First Name*
Last Name* Last Name*
Address* Home Phone
City* Work Phone
Zipcode* Cell Phone
Email Address* Email Address*
School May we take pictures and/or video of your child for CRV records? Yes  No
Teacher Does your child need and special accommodations? Yes  No
Date of Birth   Does your child have a peanut or other food allergy? Yes  No - Food:
ADDITIONAL INFORMATION
Would you like to attend? Yes  No  
Are you willing to drive? Yes  No
Note: Drivers required to provide a copy of drivers license and proof of insurance.
 
No. of available seat belts (including driver)?