Girl Power in STEM

Date: April 27, 2018
Time: Check-in 8:00 a.m. Ending 3:30 p.m.

NOTE: Please register only 10 girls per school. If you want to register more please contact Michelle Talley (talley.michelle@gmail.com) to be put on a waitlist. If room is available we will be able to add more from your school.

University of Central Arkansas
Lewis Science Center
Conway, AR 72035

Teacher's Name *
School *
School's Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Teacher's Email *
Teacher's Contact Phone Number * - (###) - ### ####
Additional Chaperone Name
Additional Chaperone Email
Additional Chaperone Phone Number - (###) - ### ####
1. Student Name First Last
T-shirt Sizes for Student 1
2. Student Name First Last
T-shirt Sizes for Student 2
3. Student Name First Last
T-shirt Sizes for Student 3
4. Student Name First Last
T-shirt Sizes for Student 4
5. Student Name First Last
T-shirt Sizes for Student 5
6. Student Name First Last
T-shirt Sizes for Student 6
7. Student Name First Last
T-shirt Sizes for Student 7
8. Student Name First Last
T-shirt Sizes for Student 8
9. Student Name First Last
T-shirt Sizes for Student 9
10. Student Name First Last
T-shirt Sizes for Student 10
Please list any special dietary needs. If none please type N/A. *