PWNR Registration

This form is the 2010 PWNR Registration Form. In order to attend the after party you MUST complete the form below. After submitting the form you will receive a confirmation email--please follow all directions in the email. All fields MUST be filled in to submit form. Questions? Contact Amy Williams at PWNR2010@gmail.com or call 773.308.3515.

First Name

Last Name

School Name

Your Address

City

State

Zip Code

Phone Number Type

Phone Number

Do you receive text messages?

	Yes
	No

Email Address

The next questions are concerning if you are taking a date to the event. If you are not taking a date skip the next set of questions. If you are taking a date, your date MUST complete their own waiver and have it signed by a parent or guardian if they are under 18.

Date's Full Name (First & Last)

Does your date go to your school?

	Yes
	No

Emergency Contact Name (First & Last)

Emergency Phone Number

Parent's Full Name (First & Last)

Parent's Phone Number

Parent's Signature

My Student can stay until 4:00am

READ ALL OF THESE INSTRUCTIONS BEFORE CLICKING SUBMIT!

1. Click Submit
2. Click View/print this submission
3. Click Printer-friendly view (at bottom of page)
4. Print page for your records
5. Get parent's signature and bring with you to PWNR

DO NOT GIVE THIS FORM OR PAYMENT TO ANYONE AT YOUR SCHOOL ONLY GIVE THIS TO A PWNR REPRESENTATIVE.

4839 W. Irving Park Rd. Chicago, IL 60641

Phone: 773.794.3300 ext 20

Fax: 773.286.6446

Funding for the Whats Good Program was made possible through a grant provided by the Community Based Abstinence Education Program (93.010) from the Administration for Children and Families-FYSB Division. The views expressed in this website do not necessarily reflect the official policies or opinions of of the Department of Health and Human Services.