Your Name:

Home Address:

City:

State: Please select . . . Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico New York Nevada Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin West Virginia Wyoming

ZIP:

Home Phone with Area Code::

Office Phone with Area Code::

*E-mail address:

*Verify your e-mail address:

Course(s)/Grade(s) Taught:

School:

School Address:

School City/State/ZIP:

County:

FEES/PAYMENT OPTIONS

Registration fee is $198. Grants (and registration fee) cover all costs, including: TWO HOURS of UIU GRADUATE CREDIT, materials, resource binder, meals, snacks, meeting facilities and motel lodging. (Audits & other types of credit are not available.)

Payment methods include: Check one
$98 deposit check
                Check payable to UIU. $100 balance due at workshop.
                Mail check to address at the bottom of this form.
$198 deposit check

PREFERENCES: Please answer all quuestions.

May we include your name, address, phone and e-mail address on a carpool list? Yes No

Vegetarian meals desired? Yes No

Do you have other dietary needs? Please list.

Do you need lodging? Yes No

Gender: Female Male

Do you prefer a single room? (extra charge-1/2 room price) Yes No

Roommate request?
(Lodging will be reserved for you.)