Please fill out and submit the card below to apply for admission to the 2011-2012 Junior Assembly Cotillion waiting list.

Junior Assembly Registration

Name Male Female Current Grade Year
Address City & Zip
Elementary & Middle Schools
Parents Name (Dr. & Mrs., Mr. & Mrs., Ms.)
Mom's first name(Mom's work phone)
Telephone (h)(c)E-Mail
JA brothers/sisters
Adult Reference
Notes(optional)

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