EmailMe Form - New Member Form Student Information

New Member Form Student Information

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Please make certain all blanks are filled in completely. If your documents have something you cannot read, check with your client on correct spelling of names and email addresses so we get it correct in our members set up.

When you enroll a new member, we really appreciate it if you call us to alert us of the enrollment so we can begin the process of setting the student and family account up in our support system. You should contact our 800 743 4731 number and speak with whomever answers or leave a detailed message so we can call you right back.

If using Fax, Fax all documents including a photo copy of any checks to 888 743 4731. If you do not have fax services, you may scan your documents and send them to info@powt.org with the words NEW MEMBER in the subject line.

We will confirm receipt via phone or email and your new member will hear from us the following business day after submission. Complete this submission form for each student who is to be enrolled. Congratulations and thank you for the new member.

Student Name *
First MI Last
Student Email *
Student Cell Phone *
### - ### - ####
Student Birthdate *
MM / DD / YYYY
Parent 1 Name *
First MI Last
Parent 1 Email *

Confirm Please
Parent 2 Name (please provide for email notification)
First MI Last
Parent 2 Email

Confirm
Address *

Street Address City State / Province / Region Postal / Zip Code
Parent's Cell Phone *
### - ### - ####
High School Graduation Date *
MM / YYYY
Name of High School *
High School Counselor
First Last
Interviewer *
First Last
Interviewer/Volunteer Personal Email address. *
Submission Date *
MM / DD / YYYY
Other information regarding student recommendation. Add as much information as you wish this field will take lots of input. If sponsoring organization is paying, please include payment instructions here. (i.e. Card or checking numbers etc.) You may always reach our processing center at 800 743 4731 EXT 2 *
Special notations about students or family members you think we should know. This field takes a lot of data so be as detailed as you wish.

*NOTE When adding more than one student for the family, you may click the back arrow on your browser after submission to take you back to the previous submission so you may change only the fields that are different for the next student. This can save you some time on data entry if you wish. Thanks again for the new members.