MicroTEC Application - Great River TEC

Online Application

Candidate (& Parent for those under Age 18): Please complete the online MicroTEC Application below. Online applications require full $35.00 registration payment at time of online application submission.

For questions, call: Dave Cawthon (217) 440-4244

"*" indicates required fields

Candidate Information

Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Birthdate*

Month

Day

Year

Age*

Name of Person to be contacted in case of emergency:*

Phone of Person to be contact in case of emergency:*

Medical Release Form (Required For Those Under Age 18)

For those Under Age 18: The Following Medical Release Form is Required:

I give permission for my child:

Child's Name

to be treated by a doctor in case of an emergency during the Micro TEC weekend. I further release Great River TEC from liability for any physical injury that my child might incur in conjunction with the Micro TEC weekend.

Describe an medication(s) that your child is allergic to:

Parent Name

Electronic Signature

Please type your First and Last Name

Agreement

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above terms.

Payment Information

The cost of the MicroTEC is $35.00. Full payment is due with application to hold your place.

Payment*

$35 Registration Fee - Pay Online

I have made prior arrangements

Please describe alternative payment arrangements

If you have made prior payment arrangements (such as financial assistance or parish assistance, please provide details here)

Total Amount Due Now

Comments

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