Registration Form: (Please Fill In Completely)

Name: (Last) (First)

Years Teaching

School District:

School:

School Address: City: Zip Code:

School Phone:

School Email:

Home Address: City: Zip Code:

Home Phone: Cell Phone

Home Email:

Languages (Subjects) Taught: Levels Taught: Years Teaching:

Please select 2 choices from the below retreats in case the one you want is filled:

Poster Making: 1st Choice: Select June 11 - 13 June 18 - 20 2nd Choice: Select June 11 - 13 June 18 - 20

Games: 1st Choice: Select June 16 - 18

Student Notebook: Select June 13 - 15

Teacher Recharge: Select Aug 6 - 8

Combination Retreats:

Poster & Notebook Select June 11 - 15

Notebook & Games Select June 13-18

Games & Poster Select June 16 - 20

Comments (if applicable):

Payment Options: (please select one) Select Purchase Order Credit Card Personal Check