ACT-SO CULINARY ARTS REGISTRATION FORM

Academic, Cultural, Technological, and Scientific Olympics

Bloomington-Normal NAACP ACT-SO
P.O. Box 385
Bloomington, IL 61702

Date Date / MM / DD YYYY
Student Profile
Name Name First Middle Last
Age
Date of Birth Date of Birth / MM / DD YYYY
Gender

Gender Male Female Other
High School
Grade
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Email
Parent/Guardian Name Parent/Guardian Name Title First Last Suffix
Parent/Guardian's Cell Parent/Guardian's Cell - ### - ### ####
Parent/Guardian Email
How did you hear about ACT-SO?
*

Newspaper Radio Web site Student Ambassador Teacher Former Participant ACT-SO Volunteer Social Media Other Other
Are you a McLean County Resident?

Are you a McLean County Resident? Yes No
Please select the categories of interest to you.

(Three (3) categories maximum)
CULINARY

CULINARY Culinary Arts (previous or current culinary education required)
Media Release

I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or video tapes of the Student named above. I also grant to the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release the Bloomington-Normal ACT-SO and its volunteers from all claims, demands, and liabilities whatsoever in connection with the above.
*

I give parental consent. I DO NOT give parental consent.
Parent and Student Accountability

The mission of the Bloomington-‐Normal ACT-‐SO program is to nurture excellence and provide positive reinforcement to African-‐American high school students. We will accomplish this by engaging students in a quality 7-‐month program of monthly enrichment sessions, educational/informational sessions, a community volunteer project, mentoring opportunities, field trips, and more. Students are expected to be fully engaged and committed; and their parents/guardians are expected to support, monitor, and encourage their participation.

Through the commitment of our supporters, partners, volunteers, and steering committee, we will provide leadership, encouragement, and guidance. The responsibilities of parents and students are as follows:
Please check boxes *

Please check boxes Complete student registration paperwork and pay $40 enrollment fee Attend the monthly Enrichment and Coaching Sessions Volunteer ten (10) hours per family. Sell banquet tickets and ads for the awards ceremony souvenir book
Student Name Student Name * First Middle Last
Student Signature *

Clear
Date Date / MM / DD YYYY
Parent/Guardian Name Parent/Guardian Name * First Middle Last
Parent/Guardian of Participant Signature *

Clear
Date Date / MM / DD YYYY
Registration: $40

(Includes a year membership in the NAACP and a monthly subscription to the CRISIS Magazine.)

A processing fee has been included for credit card payments. You will be redirected to PayPal to make payment when submitting this form.
$0

Total

ACT-SO CULINARY ARTS REGISTRATION FORM

ACT-SO CULINARY ARTS REGISTRATION FORM

Student Profile

How did you hear about ACT-SO?

Please select the categories of interest to you.

Media Release

Parent and Student Accountability

Registration: $40

$0

Total

$`0`