EmailMe Form - 2012 Student Convention Registration

Name *
First Last
CEGEP, College or University *
Organization *
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Cell Phone *
### - ### - ####
E-mail Address *
Will you be staying at the hotel? *
How would you like to pay? *
How did you hear about the Convention? *