Girls Who Tech Pitch Weekend

First Name of Student*

Last Name of Student *

Student Current Grade*5678

Name of Current School*

Primary Family Address*

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Address 1:

City:

Country:

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Postal Code:

First Name of Parent/Caregiver 1*

Last Name of Parent/Caregiver 1 *

Parent/Caregiver 1 Email Address*

Parent/Caregiver 1 Phone Number* - -

First Name of Parent/Caregiver 2*

Last Name of Parent/Caregiver 2*

Parent/Caregiver 2 Email Address *

Parent/Caregiver 2 Phone Number * - -

Emergency Contact Name*

Emergency Contact Phone Number * - -

Student T-Shirt Size*

Dietary Restrictions?*

I give permission for photo/video footage of my student to be used from GWT Pitch Weekend *YesNo

I understand that this video/photos of my student may be used on LWGMS' website, social media, or other admissions and marketing materials.

Registration Fee$50.00

I would like to pay for the credit card processing fees.

Subtotal: $

Fees: $

Grand Total: $

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Email Associated with Payment:*

Credit or debit card*

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