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!!

Students (online registration)

First Name MI
Last Name

School Name
(i.e., NAME Middle School)

Sponsor Name (optional)
(i.e., school/group coordinator, person recommending student attend - non parent/guardian)

Age Grade

Address Address2

City State Zip Code

Email Address

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

Parent / Guardian

Parent / Guardian Telephone Number (###) ###-####

Physician

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 registration/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/