Pathways to the Future-11-10-2012

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1. Please provide the following information for EACH PERSON in your family/group that will be attending the regional event: "Pathways to the Future" - Saturday, November 10, 2012 at Chancellor High School -6300 Harrison Rd. Fredericksburg, VA 22407. THE INFORMATION BELOW IS FOR PERSON #1. All information is confidential.
*
2. Is Person #1:
3. For Person #1 only
Student - What is the name of your school?
Educator - What is the name of your School Division?
Agency - What is the name of your Agency?
4. Register Person #2 for Pathways 2012.
5. Is Person #2:
6. For Person #2 only
Student - What is the name of your school?
Educator - What is the name of your School Division?
Agency - What is the name of your Agency?
7. Register Person #3 for Pathways to the Future 2012.
8. Is Person #3:
9. For Person #3 only
Student - What is the name of your school?
Educator - What is the name of your School Division?
Agency - What is the name of your Agency?
*
10. Does anyone in your family/group need special accommodations? (We must have 2 weeks notice)

If YES, Please specify needed accommodation(s) below.
11. BY REGISTERING AND PARTICIPATING IN Pathways to the Future 2012, YOU ARE AGREEING TO BE PHOTOGRAPHED AND/OR VIDEOTAPED FOR PUBLICITY PURPOSES AND RELEASE THE DISABILITY RESOURCE CENTER, ITS OFFICERS, EMPLOYEES AND AGENTS FROM ANY LIABILITY RESULTING FROM OR CONNECTED WITH THE PUBLICATION OF THIS INFORMATION.

OPT OUT FORMS WILL BE AVAILABLE AT THE REGISTRATION DESK ALSO.
IF YOU WOULD LIKE TO OPT OUT NOW, PLEASE COMPLETE BELOW:
12. Optional information. Please check all that applies to your family.
Thank you for registering for the Regional Event: Pathways to the Future 2012.
If you have any questions, call the disAbility Resource Center at 540-373-2559
or email Kim Lett- klett@cildrc.org

"We look forward to seeing you Saturday, November 10, 2012 at Chancellor High - 6300 Harrison Rd. Fredericksburg, VA 22407. Registration begins at 9:00 AM."