REGISTRATION FORM Register online at www.unitedachievers.org or call 905-455-6789 PARTICIPANT’S INFORMATION First Name:
Last Name:
Address:
Apt:
City:
Prov:
Postal Code:
Date of Birth: (DD/MM/YYYY)
Age:
School/College/University:
Grade/Year:
Work: Tel: (
Sex:
M
F
Occupation: )
Cell: (
)
Email:
FAMILY CONTACT INFORMATION Parent/Guardian: Address: Tel: (
)
Cell: (
)
Email:
WHAT’S YOUR INTEREST? CHOOSE YOUR TOP THREE We will offer training in a variety of art disciplines in addition to life skills and development workshops. Select the top 3 art forms in which you are interested. Number your top 3, with 1 being your No 1 choice! Dance
Photography
Special Events & Décor
Deejay
Poetry
Steelpan
Music Production
Roger TV Multimedia
Urban Arts
Signature (Parent/Guardian if under 18)
Date (MM/DD/YYYY)
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United Achievers’ Community Services, Inc. 36 Queen Street East, Lower Level, Brampton, ON L6V 1A2 Tel: 905.455.6789 Fax: 905.455.6162
[email protected] www.unitedachievers.org
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