1. ‘JUMP START YOUR FUTURE’
Celebrating the ‘Month of the Military Child’
College and Career Workshop REGISTRATION
The Georgia National Guard Youth Program is committed to the development and
success of our military youth. “Jump Start Your Future” is designed to provide parents &
youth with the opportunity to receive information that will assist in making informed
decisions for the future.
DATE: Tuesday, April 3, 2012
LOCATION: Georgia State University
Student University Center/Capital Suite
44 Gilmer St.
Atlanta, GA 30302
REGISTRATION & Continental
BREAKFAST: 8:00AM-8:45AM
TIME: 8:45AM-12:00PM
**Workshop sessions will begin promptly at 8:45AM**
Please complete all items in the registration packet and submit by no later than
Monday, March 26, 2012. All registrants must be in grades 8-12.
If you have any questions regarding the registration process, please contact Kara B.
Coleman Child or Mark Richards.
Kara B. Coleman, MSW, LCSW
Child & Youth Services Director
Office: 678-569-5860
Cellular: 678-656-4437
Mark Richards
State Youth Coordinator
Office: 678-569-5761

2. SECTION I: REGISTRANT INFORMATION (Please print or type)
Youth Registrant's Name:
____________________________________________________________
Last First MI
Name you prefer to use: _______________________
Email Address: ______________________________
Home Phone: ________________________ Cell Phone: _____________________________
Address:
___________________________________
___________________________________
___________________________________
Date of Birth: __________________________ Age:___________
Gender (circle one) Male/Female
School: _______________________________________ Current Grade: ______ GPA: ______
Emergency Contact: Name_________________________________________________
Phone Number:_______________

3. SECTION II: PARENT or LEGAL GUARDIAN INFORMATION
Mother/Legal Guardian:
Name: ________________________________
Daytime Phone Number: _____________________ Cell Phone Number: __________________
Evening Phone Number: ______________________
Email Address: ___________________________________
Father/Legal Guardian:
Name: ________________________________
Daytime Phone Number: _____________________ Cell Phone Number: __________________
Evening Phone Number: ______________________
Email Address: ___________________________________
Unit family member is assigned to:
______________________________________________
Branch of Service: _______________________________
TOTAL PARTICIPANTS ATTENDING WORKSHOP: _______
SECTION III: PHOTO/PRESS RELEASE
I hereby grant the Georgia National Guard the right and permission to use and publish the
photographs/video material taken at youth events in order to develop photographic and

4. multimedia materials. These materials may be used to advertise, market, and promote the
Youth Program. I understand that identifying information (e.g. name, address, or city) will not be
used in this media without my permission.
________________________________________________________________________
Parent/Guardian Signature Date
Please mail, email or fax registration forms to:
Kara B. Coleman, MSW, LCSW
Child & Youth Services Director
Georgia National Guard
Family Program Office
5019 GA Hwy 42, Suite 120
Ellenwood, GA 30294
Fax: 678-569-5366
kara.b.coleman@us.army.mil
www.GeorgiaGuardFamilyProgram.org/youth