Student Registration Form For Expanding Your Horizons Career
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1Student Registration Form for Expanding Your Horizons
Career Conference for Girls
First Name:
Last Name:
Address:
City:
State:
Zipcode:
E-mail:
Phone Number:
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)
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Emergency Contact Name:
Emergency Phone Number:
(
)
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Grade: _________
School:
Session topic preference (Circle One):
Biology
Engineering
Chemistry
Physics
Math
Health
Name of Accompanying Adult (if applicable):
I understand that by registering for the conference, I give permission to Math/Science Interchange to use
pictures of me or my child taken during the conference for advertising purposes.
Signature of Parent/Guardian:
Date:
Please mail this form and your registration fee of $15 per student (checks can be made payable to
“Math/Science Interchange”) to:
EXPANDING YOUR HORIZON
Attn: Sharon Drummond
Math/Science Exchange
2700 Neilson Way, #924
Santa Monica, CA 90405
Telephone: (310) 463-2008
E-mail:
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