Educational Talent Search Program
Fall 2009

Dear students and parents:,

For planning purposes, please check the sessions you are interested in attending:

When you have completed the registration form, be sure to click the "submit" button at the bottom of the page.

Thank you for your participation.

Please select the date you will be able to attend.
September 19 October 10 November 7 November 21
December 5

Profile Information

*Denotes a required field.

Are you the:    Parent Registration       or the    Student Registration

Last Name:*
First Name:*
Middle Initial:
Street Address:* (and apartment number, if applicable):
City:*
State:*
Zip:*
Home Phone:*
Cell:

E-Mail:*

High School:*
Mother/ Guardian:*
Father/ Guardian:*
Work Phone:
Work Phone:
Alt. Phone:
Alt. Phone:
Email:
Email:
Any known medical condition?
  Yes No
If Yes, please explain:
Emergency Contact:
Contact Name:
 Relationship:
Phone: