Registration form for non-Columbus State students to attend the November 8-9, 2013 Collegiate Leadership Conference of Ohio.

1. A Leader’s Legacy:
Making history every day
November 8 & 9, 2013
Non-Columbus State Student Registration Form
Name (Print clearly) ____________________________________________________________
Email Address ________________________________________________________________
Street Address ________________________________________________________________
City ___________________________________ State ___________ Zip Code ___________
Telephone ____________________________________________________________________
College or University ___________________________________________________________
T-Shirt Size: S M LG XL XXL
*Are you a First Generation College Student?
There is a special track just for you! Please check the box below if you and/or your family will arrive early at 3
p.m. Following the reception, your family will be invited to attend a free workshop. Please visit our website for
more information.
[ ] I am a first generation college student (I’m the first in my family to attend college)
[ ] I will attend the reception.
[ ] My family will attend (#______members) the reception.
Registration Fees postmarked by October 15, 2013:
[ ] General Registration for Non-Columbus State Community College Students, $30
[ ] Group Registration (ten or more), postmarked by October 15, 2013, Number Registered:______
($30 a person and get the tenth student free)
[ ] Late Registration (postmarked by October 25, 2013) $40
Check this box if you need a vegetarian boxed lunch option [ ] Quantity: _____
If you have special needs or require assistance please contact us before the conference so that we can
accommodate you.
Please Mail Registration Form to:
Columbus State Community College
Student Engagement and Leadership, Nestor Hall 116
ATTN: Kimberly Rhyan
550 East Spring Street / Columbus, OH 43215
Phone: (614)287-3621 Fax: (614)287-3683
Make Checks Payable to:
Columbus State Community College