AA-NSBE FreshStart Registration Form Fall 2009

Austin Alumni Chapter of the
National Society of Black Engineers
AA-NSBE FreshStart Fall 2009
Registration/Permission Form

Saturday, November 14, 2009
8:30 am – 4:30 pm

Registration opens: 8:00 am

- Location -
Applied Materials, 9700 E Highway 290,
Austin, TX
(hwy 290 east towards Houston;
east of IH 35, east of hwy 183)

Students grades 6 – 12
Free admission
includes breakfast & lunch
Door prizes

- pre-registrants-
sign up here, then
please bring your signed
permission forms to the
registration area!!

Parents/Adults (online registration)

First Name MI
Last Name

Your Child's School Name
(i.e., NAME Middle School)

Address Address2

City State Zip Code

Email Address

Phone (###) ###-####

Physician (optional)

Physician Telephone Number (###) ###-####

Emergency Contact Person (optional)

Emergency Contact Telephone Number (###) ###-####

How did you hear about FreshStart? (select all that apply)

soulciti.com		radio	News8	newspaper	AA-NSBE
Freescale		Dell	3M	IBM	Aplied Materials

other sources/details

Check if you have attended a FreshStart program before?

If yes, please list

Comments:
(any special dietary needs? any problems with the form? ......)

Please remember: after submitting your online registration data,
mail signed permission form to P.O. Box address &/or bring to event
(Word | PDF)


We look forward to a day filled with learning and fun. For more information, please visit the AA-NSBE FreshStart Web page at http://www.aansbe.org/freshstart.html or send an email to freshstart@aansbe.org and a FreshStart representative will respond.

Registration must be received by November 10, 2009.

Mail Completed Form: AA-NSBE ATTN: FRESHSTART COMMITTEE P O BOX 684769 AUSTIN, TX 78768-4769						Additional Contacts AA-NSBE PCI Chair, pcichair@aansbe.org OR AA-NSBE President, president@aansbe.org OR log on to http://www.aansbe.org/