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: Select n/a

Games: Select n/a

Teacher Recharge: Select n/a

Student Notebook: Select n/a

Combination Retreats: Poster & Games Select n/a

Combination Retreats: Teacher Recharge & Student Notebook Select n/a

Comments (if applicable):

Payment Options: (please select one) Select Mail in Purchase Order Mail in Check Call with Credit Card

Please call 713-515-0789 with your credit card information.