Registration Form

Collaboration in Action:
Promoting Residentially Based Education

October 15-17, 1998

One form per delegate, please. You may photocopy this form as necessary. Please print this form on your printer and mail or fax to the address below. Please do not submit via the internet, as we do not yet have a secure internet server.

Please Note:
For best rates, we must receive your registration form no later than September 11, 1998
(The registration deadline has been extended from the original September 4th deadline.)

 
Name: _____________________________________________________________________________

Title: ______________________________________________________________________________

Program/Organization: _______________________________________________________________

Institution: _________________________________________________________________________

Address: ____________________________________________________________________________

City: ________________________________ State: _____ ZIP: ____________________

Phone: ______________________________ Fax: _____________________________________

E-mail Address: _____________________________________________________________________

 

Registration fees:

Circle One:

Received by
September 11th

Received after
September 11th

Comments

 

 

 

 

Full Participant

$175

$250

Late registrations will be accepted on a space-available basis only.

Primary Presenter

$125

$125

Limited to one per program; additional presenters must register at Full Participant rate.

Full-Time Student

$60

$60

Please, full-time students only.

Pre-Conference Workshop #1
Making Our Case

$50

$75

Pre-Conference Workshop enrollment is limited. Workshops will take place on Thursday, October 15th from 8:30 - 11:30 a.m. Reservations will be accepted on a first-come, first-served basis. Workshop fee includes lunch on Thursday, October 15th.

Pre-Conference Workshop #2
Eco/Geo Lake Champlain

$50

$75


Total enclosed: $____________________

Payment form:

____ Check
____ Purchase Order #___________________ (Please include a copy of PO with registration.)

____ VISA ____Mastercard

Credit card number: ___________________________ Expiration date________

Signature of Cardholder: ________________________________________

 ____ Please check here if you require special accommodations, such as sign interpretation. (Conference staff will contact you. Reasonable accommodations will be made provided that we receive your request at least 30 days prior to the conference.)

A confirmation letter will be sent within 10 days of receipt of registration. Cancellation of registration will be refunded minus a $25 handling fee until September 18, 1998. No refunds will be issued after September 18, 1998. Substitution of participants is accepted.


Hotel Information: The Radisson Hotel Burlington is the official conference hotel. A limited number of rooms are being held at special conference rates until September 15, 1998. For reservations, contact the Radisson at (800) 333-3333 or (802) 658-6500. October is Vermont's peak foliage and tourism season; we strongly recommend you make your reservations well in advance.


Fax or mail this registration form to:

Collaboration in Action Conference Registration
University of Vermont
Division of Continuing Education
30 South Park Drive
Colchester, VT 05446

Fax: (802) 656-3891
Phone: (802) 656-2088

(Please do not submit via the internet, as we do not yet have a secure internet server.)