College Admission Pursuit

"Education is the most powerful weapon
which you can use to change the world."
-Nelson Mandela

"BRAINSTORM, BEGIN AND BEYOND"

A 3-day college essay writing experience

Registration Form

Student's First Name

Student's Last Name

Parent/Guardian's First Name

Parent/Guardian's Last Name

Student's Email Address

Parent/Guardian's Email Address

Phone Number
We will not call you unless there is a change to the event you are registering for.

Name of School Currently Attending

Student's Current Grade Level

How did you hear about this workshop?

Food and Other Allergies
Please list ALL food allergies and any other allergies we should be aware of. PLEASE indicate NONE in this section if the student does not suffer from any allergies.

Learning Differences or Behavior Disorders
Does the student have any Learning Differences or Behavioral Disorders we should be aware of? Please note: If the student requires an accommodation, we will contact the parent/guardian directly to discuss the specific needs of the student, prior to the date of the workshop.

First and Last Name of Emergency Contact
Please indicate who we should contact in the event of an emergency, on the date of the workshop.

Relationship to Student

Emergency Contact Phone Number

Additional Information
Is there anything you think we should know to ensure an awesome experience for the student?

Payment Information

Email Address
The email address your receipt should be sent to.

Credit Card Number

CVC Code

Card Expiration