Peer Education - Texas FCCLA
Peer Education - Texas FCCLA
Peer Education - Texas FCCLA
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2012 <strong>Peer</strong> <strong>Education</strong> and Career Showcase<br />
Region : _______ Chapter ID: ______________________<br />
Chapter Name:___________________________________<br />
School Name: ___________________________________<br />
School Phone: __________________________________<br />
School Address: _________________________________<br />
City: __________________________________________<br />
State: _______________ Zip: ______________________<br />
Advisor Name: __________________________________<br />
Cell Phone: _____________________________________<br />
Address: _______________________________________<br />
City: __________________________________________<br />
State: _______________ Zip: ______________________<br />
Additional Adult Information:<br />
Name: ___________________________________________<br />
Address: ________________________________________<br />
City: ______________________State: ____ Zip: ________<br />
Cell Phone: _____________________Gender (M/F) _____<br />
Email: __________________________________________<br />
Bus Driver Sleeping Room Needed (Y/N) Sat ____Sun____<br />
($120/night– tax included, based on single occupancy)<br />
Student Roster<br />
*Limit 10 students & 1 advisor per chapter– An additional<br />
adult participant may attend but must pay registration<br />
and $40/night for hotel accommodations and materials.<br />
Please choose one of the following options:<br />
Option A: <strong>Peer</strong> <strong>Education</strong> Training &Career Showcase – Sept. 15-17, 2012<br />
Option B: <strong>Peer</strong> <strong>Education</strong> Training ONLY— Sept.16, 2012<br />
Option C: Career Showcase ONLY— Sept. 17, 2012<br />
Registration<br />
(Option A)<br />
Number of Students________<br />
One Advisor _______<br />
Additional Adult _______<br />
(Option B)<br />
Number of Students________<br />
One Advisor _______<br />
Additional Adult _______<br />
(Option C)<br />
Number of Students________<br />
One Advisor _______<br />
Additional Adult _______<br />
Saturday, September 15- Dinner (optional)<br />
x $15.00 = ____________<br />
$15.00 = ____________<br />
$15.00 = ____________<br />
x $10.00 = ____________<br />
$10.00 = ____________<br />
$10.00 = ____________<br />
x $5.00 = ____________<br />
$5.00 = ____________<br />
$5.00 = ____________<br />
Number of Participants______<br />
Saturday Night Hotel Accommodations<br />
Number of Students ________(complimentary, quad occupancy)<br />
One Advisor (complimentary, quad occupancy)<br />
x $20.00 = ____________<br />
Additional Adult _________ (quad occupancy)<br />
Sunday, September 16- Lunch (complimentary)<br />
Number of Participants______<br />
Sunday Night Hotel Accommodations (tax included, quad occupancy)<br />
x $40.00 = ____________<br />
Number of Students______<br />
x $30.00 = ____________<br />
One Advisor______<br />
$30.00 = ____________<br />
Additional Adult______<br />
$40.00 = ________<br />
Bus Driver Hotel Accommodations (tax included, single occupancy)<br />
Saturday, September 15, 2012 _______ x $120.00 = _________<br />
Sunday, September 16, 2012 _______ $120.00 = _________<br />
<strong>Peer</strong> <strong>Education</strong> T-Shirts<br />
Small____ Medium___ Large____<br />
X-Large____ XX-Large ____ XXX-Large____<br />
Areas of Training Available:<br />
Civic Engagement, Financial <strong>Education</strong>, Fraud, STOP the Violence or Teen Safe Driving<br />
Each chapter may register ONLY 2 participants per area of training<br />
Student Name Grade (M/F) Area of Training<br />
1. __________________________________________ _______ _______ ___________________________<br />
2. __________________________________________ _______ _______ ___________________________<br />
3. __________________________________________ _______ _______ ___________________________<br />
4. __________________________________________ _______ _______ ___________________________<br />
5. __________________________________________ _______ _______ ___________________________<br />
6. __________________________________________ _______ _______ ___________________________<br />
7. __________________________________________ _______ _______ ___________________________<br />
8. __________________________________________ _______ _______ ___________________________<br />
9. __________________________________________ _______ _______ ___________________________<br />
10. __________________________________________ _______ _______ ___________________________<br />
Total Number of T-Shirts x $10.00= _________<br />
Total Due: ____________<br />
*Postmark deadline<br />
for entry is:<br />
Friday, August 31, 2012<br />
*Advisors will receive a<br />
confirmation email by Tuesday,<br />
September 11, 2012. (if you do not receive an<br />
email by the stated date, please contact the<br />
<strong>Texas</strong> <strong>FCCLA</strong> office at 512-306-0099)<br />
*You must present your<br />
registration confirmation<br />
email/receipt upon arrival<br />
*There will be NO<br />
onsite registration<br />
Please mail form and make all checks/money<br />
orders payable to :<br />
<strong>Texas</strong> <strong>FCCLA</strong><br />
Lock Box Operations<br />
P.O. Box 1326<br />
San Antonio, TX 78295-1326
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