Please fill out the form below with the following information:

• Financial information
• Student name corrections (if they are incorrect on the results spreadsheet)
• MENC Card number and expiration date

Check should be made out to Atlee High School High School and sent to the address below

Atlee High School
Attention: R. Paul Rozecki, Jr.
9414 Atlee Station Road
Mechanicsville , VA 23116

Important Deadlines to remember

Registration form- Friday, January 6, 2012
Payment postmark- Friday, January 13, 2012

If registration and/or payment is not received by the above due dates, you will forfeit
your opportunity to participate in this District One event.

If you have students who are not participating, please send an email to me at rrozecki@hcps.us
immediately so that alternates may be notified.

If you have any questions, or need further assistance, please do not hesitate to contact me at 804-723-2126 or email me at rrozecki@hcps.us.

(* required fields)

* School:

* Address/City/Zip:

* email

Director names

* Name: * Phone:

*Menc #: *Exp. Date:

  Name:    Phone:

Menc #: Exp. Date:

 

  Name:    Phone:

Menc #: Exp. Date:

* Enclosed are Student fees
@ $25.00 each. * Total $

* Director meals # @ $12.50 each. Total $

Non-member fee if applicable ($107) $

* Total amount due: $

Student name corrections: