AYA Winter Academy 2011 Registration

Parent / Guardian Name / Sponsor Parent / Guardian Name / Sponsor First Last
Parent / Guardian /Sponsor Address Parent / Guardian /Sponsor Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone #2
Phone #2
- ### - ### ####
Phone #1 Phone #1 - ### - ### ####
Parent / Guardian / Sponsor Email
Student's Name Student's Name First Last
Student's Email Address
Student's Email Address
First Last
Student's Age
I now register my child for the Winter Academy, and the following is true

I now register my child for the Winter Academy, and the following is true I know others who I believe will benefit from this Academy I will also attend the Parent / Community Sesion (Reg. 49. Special for parents with children enrolled: ($19.00) I will not be able to attend, but would like a recording of the session ($19.00) I will not be able to attend the Parent / Community Session
I'm sponsoring multiple youth. Their contact information is below: