Registrant Details    ( required fields)

 Name

  

Title/Department

School/Affiliation

Mailing Address 1

  

Mailing Address 2

City

State          Zip       Country 

 

  

Phone (home)

 

Phone (cell/mobile)     

Email
     
  Photo Release

We will have a photographer in attendance at the conference. Candid photos will be taken to be used for purposes such as Academy membership brochures, the Academy website, etc. If you object to your image being used for these purposes, please indicate at right.

You may use
my image

   

 Travel Information

I will be arriving by

Air      Car

Airline/Flight #

Airline   Flight #

Arrival

 Date     Time  

Departure

 Date     Time  

I need driving directions          YES       NO 

I will be staying for the Weekend Academy Meeting          YES       NO 

   

 Registration Fees

Conference Registration $300

(includes yearly Academy membership fee)
 
Academy Membership Only $50

(pay this if you are unable to attend the conference but want full membership in the Academy)
 
Note:

Gaston College personnel should register with Virgil Cox.
Please call him at 704-756-2190 or email him at cox.virgil@gaston.cc.nc.us.

   

 I am paying my fees by: 

Online Payment Submit your registration and you will have the option to pay your fees online from your registration confirmation page.
I will mail a check

Checks should be payable to Academy of Process Educators and mailed to:

Dr.  Peter Smith
1036 North Niles Ave
South Bend, IN 46617

 

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