Scholarship Brunch Registration Form

Registration Form

Please complete to reserve your seat.

Space is limited to Fall 2012 scholarship recipients.

You will be directed to a confirmation page upon completed this form.
Please print for your records.

First Name: *

Last Name: *

Street Address: *

City, State, Zip: *

High School: *

Intended Major: *

Gender: *

Email Address: *

Home Phone: (no dashes) *

Cell Phone:

Number of guests attending: (including student)*

If you or your guest(s) have any specific dietary needs, please list them here:

* Field is Required.

If you have any difficulty completing this form or have any questions,
please call Karyn Tucker at 800-SUNY-123.