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

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

Girls' Names and Info:
Please submit another online form if there is not enough room for all the girls' names.

Registrant #1

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.)

Registrant #3

Registrant #4

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.

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