Partner Sites

Registration Form

Last Name:

First Name:

Address:

City:

State:

Zip:

Home Phone:

Age:

School Attending:

Grade:

Father/Guardian:

Mother/Guardian:

Cell #

Email Address:

Cell #

Emergency Contact (non-parent):

Phone #:

List any pertinent medical conditions and/or allergies:

***All cancellations are subject to a $25.00 administrative fee. Cancellations received by the May 20, 2011 deadline will receive a full refund. Cancellations made within two weeks of June 6 will receive a half-refund. Please call with any questions.

MS Tobacco Free Coalition