If registering a group or organization, please provide the Organization/Class name:

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* 1. If registering a group or organization, please provide the Organization/Class name:

If registering as an individual; Please provide your name:

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* 2. If registering as an individual; Please provide your name:

School Name

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* 3. School Name

School Address

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* 4. School Address

City and Zipcode

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* 5. City and Zipcode

School Phone Number (include area code)

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* 6. School Phone Number (include area code)

If registering a group, Name of Teacher Chaperone 

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* 7. If registering a group, Name of Teacher Chaperone 

If registering a group, Chaperone's Cell Phone

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* 8. If registering a group, Chaperone's Cell Phone

If registering a group, email address of teacher contact:

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* 9. If registering a group, email address of teacher contact:

If registering individually, your email:

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* 10. If registering individually, your email:

Programs of Special Interest at the UTHSCSA

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* 11. Programs of Special Interest at the UTHSCSA

Number of Students Attending

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* 12. Number of Students Attending

Average Age of Student Attendees

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* 13. Average Age of Student Attendees

NOTE:  All appropriate blanks must be filled in for registration to be considered complete.
NOTE:  Classes/groups should register as a class/group.  Only those students coming on their own need to submit individual registrations forms.

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