2017 Youth Conference Registration

This form will only take 5-10 minutes for completion! If you require a paper application please contact us at mechadesrjc@gmail.com or at (707) 521-6934.
This will be held on the Santa Rosa Junior College on Friday, April 21st, 2017
Name *
Nombre
Your answer
Grade *
Grado
Your answer
Age
Edad
Your answer
Home Address
Direccion
Your answer
City
Ciudad
Your answer
Date of Birth
FDN
MM
/
DD
/
YYYY
School *
Escuela
Your answer
State
Estado
Your answer
Zip Code
Codigo Postal
Your answer
Email Address *
Correo Electronico
Your answer
Phone Number *
Numero de Telefono
Your answer
Emergency Contacts/Contactos en Caso de Emergencia
Parent/Guardian *
Padre/Guardian
Your answer
Phone Number *
Numero de Telefono
Your answer
Are you allergic or require medication? *
Es alergico o requiere medicina?
If you answered yes to the question above please elaborate on the allergy or medication.
Si repondio si a la pregunta anterior por favor elabore acerca de la alergia o medicina.
Your answer
Name of Emergency Contact #1 *
Nombre de Contacto de Emergencia #1
Your answer
Phone Number of Emergency Contact #1 *
Numero de Telefono de Contacto de Emergencia #1
Your answer
Name of Emergency Contact #2 *
Nombre de Contacto de Emergencia #2
Your answer
Phone Number of Emergency Contact #2 *
Numero de Telefono de Contacto de Emergencia #2
Your answer
Do you need transportation? *
Necesita transportacion?
How did you find out about this event?
Como se informo acerca de este evento?
Your answer
What are your expectations for this event?
Caules son sus expectativas de este evento?
Your answer
Parent Permission and Authorizations/Permiso de Padres y Autorización
By checking the box below I give permission for my child to attend the M.E.Ch.A Conference and I am in agreement that he/she will abide by all rules and regulations while attending this school function at Santa Rosa Junior College. In case of an emergency I give permission for my child to receive medical treatment if needed. I also give MEChA the authorization to contact my child through phone and email for reminder and updates related to the M.E.Ch.A Conference. *
Al crosar la casilla, doy permiso para que mi hijo/a asista a la M.E.Ch.A Conference y estamos de acuerdo que él/ella respetara las reglas y regulaciones al atender este evento escolar en Santa Rosa Junior College. En caso de emergencia doy permiso para que mi hijo/a reciba tratamiento médico si es necesario. Tambien doy permiso a M.E.Ch.A. de contactar a mi hijo/hija por forma de telefono u correo electronico por propocito de recuerdos y actualización relacionados a la M.E.Ch.A Conference.
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