DATA Alumni Registration Form:

Date: _________                                                         DOB_________

Name: ________________________________________________

                                                    Last name                                                            First Name

Street Address: _________________________________________

City: _______________________________________________________________________________ Zip:______

Phone#: _____________________ E-mail: __________________

Program: Hayslip or Kelly (please circle one.) Date of Graduation:  ______

Place of Employment: ___________________________________________

Are you looking for a job? Y / N What type? ________________________

Are you in school or college, list the school: _________________________

What are your career interests?  ___________________________________
List your hobbies? ______________________________________________

Do you have any special needs?  ___________________________________

Do you belong to any groups if so list the group or groups? _____________

_____________________________________________________________

Do you help or volunteer in the community; if so where.________________

_____________________________________________________________

Describe your support system; Connections to family and friends. Positive or Negative.

Need more support in what area? __________________________

_____________________________________________________________

Comments to help us understand your needs._________________________

_____________________________________________________________

Any children: Male # (    ) Names: _________________________________

Female # (    ) Names: ___________________________________________

Would you like your name to be added to the website on line members’ directory? Yes / No if so with first name only. Please, specify  name to be used on web.______________________year of graduation____ will be added. Also do you want contact Info with your Name on the web?

Yes   No

List numbers: phone: __________________ e-mail:__________________ Address: _____________________________________________________

Support:

Family’& Friends Names: __________________________________________________

Phone #: _____________________ E-mail: ____________________________________

Street Address: ___________________________________________________________

City: ______________________________________________________Zip:__________