Annual Leadership Ceremony Registration
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May 2nd, 2012 at 5:00pm
Bedford Campus Center, Cafeteria

1. Please type your full name.

Please type your full name.

2. Please type your email address.

Please type your email address.

3. If you will have any non-student guests joining you, please indicate their names below (maximum of 3).

If you will have any non-student guests joining you, please indicate their names below (maximum of 3). Guest 1
Guest 2
Guest 3

4. Please list your respective club(s) or organization(s) of which you are a member.

Please list your respective club(s) or organization(s) of which you are a member.

5. Dietary restrictions:

Dietary restrictions: Yes	No
If Yes please explain

6. Will you or a guest require special accommodations:

Will you or a guest require special accommodations: Yes	No
If Yes please explain

For more information, please contact Debbie Jordan at 781-280-3762 or jordand@middlesex.mass.edu.

We look forward to seeing you at the 2012 Leadership Recognition Ceremony on May 2nd at 5pm in the Bedford Campus Center, Cafeteria.

Thank you