Parent Name First Name Last Name Parent's Email * Parent's Phone (###) ### #### Parent's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Attendee Name First Name Last Name Attendee's School Attendee's Age Attendee's Grade Emergency Contact First Name Last Name Emergency Contact's Email Emergency Contact's Phone (###) ### #### Does your daughter have any dietary restrictions or food allergies? If no restrictions or allergies, write NONE Does your daughter require any special accommodations (accessibility, hearing/visual assistance, etc.)? * If no accommodations, write NONE Thank you for registering for MOSAIC! In order to get to know your daughter better and to ensure the best mentor grouping during the summit, we ask that your daughter take a couple minutes to complete this short form HERE by November 14th. Any questions, please don’t hesitate to contact us (mosaic.summit1@gmail.com + 315.399.0591).CLICK HERE FOR LINK TO FORMSunday, December 7th@The Collector’s Room by Beau MondeGeneral Schedule:9:30 - 10:00AM Check-In10:00 - 10:30AM Welcome (Parents are invited to stay for our intro)10:30AM - 1:15PM Breakout Sessions, Brunch + Activities1:15 - 2:00PM Closing + Ending ActivityYou can expect an email on November 17th with additional Summit details.Thank you for the opportunity to meet and work with your daughter!Kristy Boyles + Brittany Pasut Contact Us: mosaic.summit1@gmail.com | 315.399.0591
