April 5, 2018

Workshop Registration

Options Without Walls, LLC Workshop Registration
Student Name
Prefix

First

Last

Suffix

Date of Birth (ex. 111096 for November 10, 1996)

Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Student Email

Parent/Guardian Name (required if under 18)
Prefix

First

Last

Suffix

Mailing Address (if different from above)
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Parent Email (if applicable)

Daytime Phone
### - ### - ####
Evening Phone
### - ### - ####
High School, College or University Currently Attending or Attended

If college/university, major?

If high school, current grade level?
Workshop(s) for which you are registering:
 College
Enrollment 101 
 What Parents
Need to Know 
 How to Stay in
College 
 Before
You Enter Graduate School 
The registration fee for each workshop is $200. Registration is not complete until the registration fee has been paid. You will receive an invoice via email to
pay through a secure online processor using a credit card or bank account.
Parent/Guardian Name (required if under 18)

Parent/Guardian Initials

I understand that typing my initials above acts as my electronic signature acknowledging submission of this registration form.
Student Name

Student Initials

I understand that typing my initials above acts as my electronic signature certifying my registration for the workshops checked above.

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