Medical & Photo Releases/Registration Fee/Scholarship Form
1. Print out and
complete this form.
2. Send check for $15.00 per registrant, postmarked by March
10, 2010, payable to: EYH-Sonoma County
If
the fee is not enclosed, scholarship approval has been awarded
from: Sonoma State
University's Pre-College Program
My EYH school
coordinator/ambassador EYH
Information Line (707) 664-2241 Other
Please
Print the following information:
Website
Registration Number
(Complete
your online registration first. The number is on the
last page.)
___________________________________
Student's
Last Name:
___________________________________
Student's
First Name:
___________________________________
Address:
___________________________________
City:
___________________________________
State:
___________________________________
Zip
Code:
___________________________________
Phone:
(
) _____________________________
Name
of School:
___________________________________
E-Mail
Address:
___________________________________
Parent/Guardian:
Cross
out statements below that you do not agree
with:
Yes
I
give my permission for my child to receive emergency
medical treatment and care.
Yes
I
give my permission for my child to be photographed and
videotaped and for the images to be published in
newspapers, magazines, TV, and on the Internet for the
purpose of promoting the EYH conference.
Yes
I
give permission to share my child’s address with SSU
and SRJC Outreach Services.
_____________________________________________
____________________
Parent/Guardian
- Signature
Date
_____________________________________________
____________________
Parent/Guardian
- Print Name
Date
The
day of the conference
I can be reached by phone at the above number, or at (
) ___________________________________.
This form must be post marked on or before March 13, 2010.
Mail
To:
Expanding
Your Horizons, Sonoma County
P.O. Box 14565
Santa Rosa, CA 95402-6565