EmailMe Form - REGISTRATION - YOUTH SUMMIT ON TECHNOLOGY

Parent

Student

Name

First Last

Birth date

MM / DD / YYYY

T-Shirt

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone

### - ### - ####

Cell

### - ### - ####

Email

School

Age

Career Goal/Major

College Choice

Parent/Relationship

Phone

### - ### - ####

Please indicate first, second and third workshop interest/choices

Computer Science • Engineering • Social Media • Biomedical
Aerospace • Robotics • Legos • Video Gaming

First Choice

Second Choice

Third Choice

Workshop interest other

All students will be held under the Prince George's County Public Schools Student Code of Conduct

Permission: My Son/daughter has my permission to attend the "2012 Youth Summit on Technology." My son/daughter is expected to display appropriate behavior at all times. I will not hold Patriots Technology Training Center and/or its associates responsible for any inappropriate behavior on behalf of my child. Parent Permission: My son/daughter has permission to be photographed during the Youth Summit for future use by Patriots Technology Training Center for the purpose of expanding advertisement of our programs. By submitting the form below, I agree to the terms above.