'Jump Start Your Future' College and Career Workshop Registration

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'Jump Start Your Future' College and Career Workshop Registration

  1. 1. ‘JUMP START YOUR FUTURE’ Celebrating the ‘Month of the Military Child’ College and Career Workshop REGISTRATIONThe Georgia National Guard Youth Program is committed to the development andsuccess of our military youth. “Jump Start Your Future” is designed to provide parents &youth with the opportunity to receive information that will assist in making informeddecisions for the future.DATE: Tuesday, April 3, 2012LOCATION: Georgia State University Student University Center/Capital Suite 44 Gilmer St. Atlanta, GA 30302REGISTRATION & ContinentalBREAKFAST: 8:00AM-8:45AMTIME: 8:45AM-12:00PM **Workshop sessions will begin promptly at 8:45AM**Please complete all items in the registration packet and submit by no later thanMonday, March 26, 2012. All registrants must be in grades 8-12.If you have any questions regarding the registration process, please contact Kara B.Coleman Child or Mark Richards.Kara B. Coleman, MSW, LCSWChild & Youth Services DirectorOffice: 678-569-5860Cellular: 678-656-4437Mark RichardsState Youth CoordinatorOffice: 678-569-5761
  2. 2. SECTION I: REGISTRANT INFORMATION (Please print or type)Youth Registrants Name:____________________________________________________________ Last First MIName you prefer to use: _______________________Email Address: ______________________________Home Phone: ________________________ Cell Phone: _____________________________Address:_________________________________________________________________________________________________________Date of Birth: __________________________ Age:___________Gender (circle one) Male/FemaleSchool: _______________________________________ Current Grade: ______ GPA: ______Emergency Contact: Name_________________________________________________Phone Number:_______________
  3. 3. SECTION II: PARENT or LEGAL GUARDIAN INFORMATIONMother/Legal Guardian:Name: ________________________________Daytime Phone Number: _____________________ Cell Phone Number: __________________Evening Phone Number: ______________________Email Address: ___________________________________Father/Legal Guardian:Name: ________________________________Daytime Phone Number: _____________________ Cell Phone Number: __________________Evening Phone Number: ______________________Email Address: ___________________________________Unit family member is assigned to:______________________________________________Branch of Service: _______________________________TOTAL PARTICIPANTS ATTENDING WORKSHOP: _______ SECTION III: PHOTO/PRESS RELEASEI hereby grant the Georgia National Guard the right and permission to use and publish thephotographs/video material taken at youth events in order to develop photographic and
  4. 4. multimedia materials. These materials may be used to advertise, market, and promote theYouth Program. I understand that identifying information (e.g. name, address, or city) will not beused in this media without my permission.________________________________________________________________________Parent/Guardian Signature Date Please mail, email or fax registration forms to: Kara B. Coleman, MSW, LCSW Child & Youth Services Director Georgia National Guard Family Program Office 5019 GA Hwy 42, Suite 120 Ellenwood, GA 30294 Fax: 678-569-5366 kara.b.coleman@us.army.mil www.GeorgiaGuardFamilyProgram.org/youth

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