Registration Form to be completed by Parents, Guardians or Teachers

The Fifth Annual Shine On! Program, Saturday, April 25 to Sunday, April 26, 2015.

No Charge. Limited Space! Register Now!

Registration Form for Teachers or Parents/Guardians to complete: please register your student(s)/daughter(s) below.

Upon completing your online registration, you will receive an automated confirmation. Please print this confirmation as it contains important information regarding the event.

Our first preference is for you to register online. If online registration is not available to you, click here for a printable registration form.

PARENTS, GUARDIANS, TEACHERS, YOUTH SERVING PROFESSIONALS: We are also offering

Workshops for adults who want to raise a confident young woman

Various Dates

Champlain Wine Company

30 City Hall Place

Plattsburgh, NY 12901

Click here for more info on the workshops for adults.

TO FAX OR MAIL YOUR REGISTRATION FORM: FAX: 518-564-4092; MAIL IN: College Auxiliary Services, SUNY Plattsburgh 101 Broad St. Plattsburgh, NY 12901

Please check relationship with attendee. *

Teacher/Parent/Guardian First Name *

Teacher/Parent/Guardian Last Name *

Grade *

Number of Girls Enrolling *

School *

Phone (Ex. 518-243-4567) *

Email *

Girls' Names and Info:

Please submit another online form if there is not enough room for all the girls' names.

Registrant #1

Please check relationship with attendee. *

Girl's First Name *

Girl's Last Name *

Address: Street/ Road/ PO Box *

City *

State *

Zip *

Age *

Please note any allergies/ Special Needs/ Medications?

T-shirt Size *

Sandwich Selection *

Parent or Guardian *

Contact Phone # (Ex. 518-243-4567) *

Email Address

Alternate Contact Name *

Alternate Contact Phone# (Ex. 518-243-4567) *

It is imperative that we have contact information for you and an alternate contact in the case of an emergency. Thank you.

Registrant #2 (If registering more than one girl.)

Please check relationship with attendee.

Girl's First Name

Girl's Last Name

Address: Street/ Road/ PO Box

City

State

Zip

Age

Please note any allergies/ Special Needs/ Medications?

T-shirt Size

Sandwich Selection

Parent or Guardian

Contact Phone # (Ex. 518-243-4567)

Email Address

Alternate Contact Name

Alternate Contact Phone# (Ex. 518-243-4567)

Registrant #3

Please check relationship with attendee.

Girl's First Name

Girl's Last Name

Address: Street/ Road/ PO Box

City

State

Zip

Age

Please note any allergies/ Special Needs/ Medications?

T-shirt Size

Sandwich Selection

Parent or Guardian

Contact Phone #

Email Address

Alternate Contact Name

Alternate Contact Phone#

Registrant #4

Please check relationship with attendee.

First Name

Last Name

Address: Street/ Road/ PO Box

City

State

Zip

Age

Any allergies/ Special Needs/ Medications?

T-shirt Size

Sandwich Selection

Parent or Guardian

Contact Phone #

Email Address

Alternate Contact Name

Alternate Contact Phone#

PHOTO RELEASE: In registering for this event, I grant Shine On the right to take photographs of my student/daughter in connection with the above-identified event. I authorize Shine On to use and publish the same in print and/or electronically. I agree that Shine On may use such photographs for any lawful purpose, including such purposes as publicity, illustration, advertising, and Web content.

CANCELLATION: There is limited space for this very popular event. If a child needs to cancel, please email Colleen Lemza at colleen.lemza@plattsburgh.edu ASAP so we can open up the spot to another girl. Thank you.

Please use the comment box below if you have any questions or additional information you would like to share with us. Thank you.

Comments?

Questions

For questions regarding registration or content, please contact Colleen Lemza, Shine On Coordinator:
Phone: 1-518-564-2408

Email: colleen.lemza@plattsburgh.edu

OR

Rachel Cusick

Phone: 518-564-3946

shineonpsu@gmail.com

Shine On Website