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District Office
916-B North River Road
Park Plaza
Halifax, PA 17032
(717) 896-7714
Fax: (717) 896-7717
Hours: 9 a.m. to 4:30 p.m.
Monday through Friday

Harrisburg Office
Room 173
Main Capitol Building
Harrisburg, PA 17120
(717) 787-6801
Fax (717) 783-3722
1-888-PICCOLA
TTY: 1-800-364-1581
Hours: 9 a.m. to 5 p.m.
Monday through Friday

15th District Map

   

Senator Jeffrey Piccola's Student Government Seminar

Student Information Registration Form

 

Advisor(s):

 
Advisor Contact Number:  

Advisor E-Mail Address:

 

School Name:

 
   

Student 1:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 2:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 3:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 4:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 5:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 6:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 7:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 8:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 9:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 10:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 11:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 12:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 13:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 14:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 15:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 16:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 17:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 18:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 19:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  

Student 20:

 

Student Name:

Home Address:

City, State, Zip:
   
Committee Choices:  Please mark 1st, 2nd and 3rd choices only per student
   
Communications & Technology  
Education  
Judiciary  
Public Health & Welfare  
Transportation  
   
   
   
   
   
 
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