Road to College Conference 2019

Online Registration Form

Date: Saturday October 26, 2019

Time: 9:00 am - 12:00 pm

Location: UC Riverside

The Road to College Conference is an opportunity for EAOP to empower students to invest in the value of higher education through identity, leadership, community involvement, and mentorship in order to provide awareness of the power of education.

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* 1. Student's First Name:

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* 2. Student's Last Name:

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* 3. Student's High School:

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* 4. Are an EAOP participant?

Yes

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* 5. Do you belong to any of the following Community Based Organizations?

BLU

Council of African American Parents (CAAP)

San Bernardino Independent Living Program (ILP)

Seventh Day Adventist Church

Heritage

MESA

Upward Bound

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* 6. Student's E-mail Address:

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* 7. Confirm Student's E-mail Address:

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* 8. Student's Phone Number

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* 9. Parent/Guardian 1

First Name

Last Name

Email Address

Contact Number

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* 10. Parent/Guardian 2 (if applicable)

First Name

Last Name

Email Address

Contact Number

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* 11. Please specify if the student or parent/guardian needs special accommodations due to a disability.

Yes

If yes please specify

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* 1. Student's First Name:

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* 2. Student's Last Name:

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* 3. Student's High School:

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* 4. Are an EAOP participant?

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* 5. Do you belong to any of the following Community Based Organizations?

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* 6. Student's E-mail Address:

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* 7. Confirm Student's E-mail Address:

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* 8. Student's Phone Number

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* 9. Parent/Guardian 1

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* 10. Parent/Guardian 2 (if applicable)

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* 11. Please specify if the student or parent/guardian needs special accommodations due to a disability.

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* 12. Please indicate the total number of guests attending, including yourself. (i.e. You and one parent = 2 guests)