MicroSociety Conference Registration Form

* Items in purple are required.
REGISTRANT INFORMATION (ONE FORM PER PERSON):
Name:
Position:
Other:
If Teacher, Grades Taught:
Subjects Taught:
 
SCHOOL/ORGANIZATION INFORMATION:
School/Organization:
Address:
City:    State: Zip:
Phone: Fax:
Your Work E-mail:


School type (Check all that apply): Public    Private    Charter    Magnet   Title I
   
HOME INFORMATION:
Address:
City:    State: Zip:
Home Phone:  
Cell Phone:      
Country (if not US):  
Your Home E-mail:      

NOTE: Conference information updates will be sent to your home email address unless otherwise requested.
 
REASONS FOR ATTENDING: (Check all that apply):
After-school
Career Awareness
Citizenship
Classroom Management
Community Service
Curriculum Integration
Drop out Prevention
Entrepreneurship
Hands-on Learning
School Climate
Student Achievement
Student Leadership
Student Motivation
Theme Exploration

Application and Enrichment of:
Language Arts
Math
Fine Arts
Science
Social Studies

Other(specify)
GRADE LEVEL INTEREST: (Check all that apply):
 
  Pre-School   Primary   Intermediate   Middle   9th    Other  

MicroSociety PROGRAM STATUS:
Is your school or organization implementing the MicroSociety program? Yes No
Please check the Microsociety programs you are implementing in your school:
Classic (During the school day program)
After School Program
Society In Action (For the social studies classroom)
Citizens in Action
For how many years has your school/organization participated in a MicroSociety program?
 
IMPORTANT, PLEASE RSVP:
I have attended a MicroSociety conference
I will attend Opening Gala, Sunday, June 29th
I will attend the Leadership Academy for administrators/coordinators
       Sunday, June 29th, 9AM-3PM (free before April 4, $25 after April 4)
I will attend the Beginner's Academy, Sunday, June 29th, 9 AM - 3 PM
      (free before April 4, $25 after April 4)
 
CONFERENCE REGISTRATION RATES:
 
Regular Registration (after April 4th) $ 495.00
Tuition exempt, per current contract (enclosed copy of current contract required)    $ 0.00
5 Paid registrations from same school (clip together)     6th registration is free  
 
BILLING INFORMATION:
Contact Person: Contact Phone:
 
PAYMENT OPTION
  Credit Card
  Check
  Payment Exempt (Tuition Exempt or 6th Registration)
 
REFER ANOTHER PERSON:
Name:
Position:
Other Job:
Phone:
E-mail: