FRA/TechConnection PROGRAM REGISTRATION FORM
Please use this form to register for all classes, workshops and
groups, even if there is no fee.
Please print, fill out and return this Registration Form to FRA, 35 Haddon Avenue, Shrewsbury, NJ, 07702.
Payment can be made by check or by credit card (American Express, Visa or
Mastercard.)
Program and Contact Information:
Program
Name:____________________________________________________________________
Program
Dates/Times:______________________________________________________________
Child’s Name_____________________________________Age:___________DOB_____________
Parent(s)
Name:____________________________________________________________________
Address:______________________________________________________________
___________________________________________________________________________________
Telephone Number:__________________________E Mail
Address:________________________
Telephone Number where you can be reached during this program:__________________
Concerns we need to be aware of for this
program:_____________________________________________
____________________________________________________________________________________
Photo Release Signature:
I, ________________________ will allow myself/my child to be photographed by FRA/TECHConnection.
The photo(s) are to be used for public relations and educational purposes. This
release allows for any form of photos to be used in connection with the agency.
___ I will NOT allow photos to be used.
Signature: ___________________________________________________Date:_________________________
Please Complete For TechConnection Computer Programs:
Diagnosis:__________________________________________________________________
Computer Skills:____________________________________________________________
Reading Level:_____________________________________________________________
Payment Information:
Amount of Payment: $____________
I am paying by:
___ Check (Number ______ )
___ American Express (Account Number:_______________________________ Exp. Date________________ )
___ MasterCard (Account Number_____________________________________ Exp. Date________________ )
___ Visa (Account Number___________________________________________ Exp. Date________________ )
___ Scholarship Needed (if available)
___ This will be paid through Real Life Choices (if applicable)
35 Haddon Avenue, Shrewsbury, NJ 07702 * Phone: 732-747-5310 * Fax:
732-747-1896
www.frainc.org ~ www.techconnection.org