** ALL REGISTRATION MUST BE DONE ONLINE**

College Bound Arkansas Student Registration
June 13-15, 2018
College Bound Arkansas registration is limited (30). Applicants will be accepted on a first come, first served basis. Priority registration will be given to first time attendees. The cost to attend is $95.00 per student. Registration deadline is May 12, 2018. For further information, contact Carrie Tuttle at (501) 505-8855 or email ctuttle@conwaycorp.net.

Student Name(*)
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Please enter your first and last name.

Gender(*)
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Street Address(*)

City(*)

State(*)

Zip Code(*)

District(*)
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Please select your district from the list.

Home Phone Number(*)
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Grade for Fall 2018(*)
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College Bound Attendance(*)
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Student Email Address(*)
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Parent Email Address(*)
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Tshirt Size(*)
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Ethnic Group(*)
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Disability Category (Please select all that apply.)(*)

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Other Disabilities
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Please list how the student will be transported to the University of Central Arkansas. List a name and contact number for the person(s) providing the transportation.(*)
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Drop off will be June 13 from 10 a.m. - 11:45 a.m.

We will be verifying your attendance one week prior to the camp. Please list a phone number we may reach you at to confirm attendance.(*)
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If you would prefer to be contacted via text message, please enter the phone number to send texts to.
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Special Dietary Needs
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Requested Accommodations Needed
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Please answer the questions below to help us provide more relevant information to you during College Bound Arkansas.

Do you currently use assistive technology?(*)
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If yes,what type?
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(cell phone, apps, note-taking devices, speech devices, audio books screen readers, dictation, etc.)

If yes, do you have a plan for maintenance for devices after high school?
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Briefly describe your plan for maintenance for devices after high school.
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If no, would you be interested in learning about a specific type of assistive technology?
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Which type of assistive technology would you be interested in learning more about?
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(note taking devices, medications reminders, etc.)

Enter the letters you see in the field provided(*)
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