Those who will be attending from Valparaiso University, please contact Melissa Desjarlais! (464-5116) 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 Student? (yes or no) 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 Car Air Airport Airline/Flight # Airline Flight # Arrival Date Time Departure Date Time I need driving directions YES NO I will be staying for the Academy Meeting YES NO I am willing to share a room at the conference hotel: YES NO Registration Fees Registration Fees (includes annual Academy membership fee & most meals from Thursday supper to Saturday lunch.) Select all options that apply. Conference Registration (does not include lodging) $350 1 Day Attendance: Thursday ONLY $100 1 Day Attendance: Friday ONLY $150 1 Day Attendance: Saturday ONLY $150 EMERITUS Conference Registration $60 Academy Membership Only $60 (pay this only if you are not attending the conference) Total Fees Owed: $ I am paying my fees by: Online Payment Submit your registration and you will have the opportunity to complete your payment online, if you wish to use a credit or debit card (we use PayPal as our payment processor). I will mail a check Checks should be payable to Academy of Process Educators & mailed to: Dr. Peter Smith 1036 North Niles Ave South Bend, IN 46617 Form Verification (anti-spambot measure): Is ice hot or cold?
Those who will be attending from Valparaiso University, please contact Melissa Desjarlais! (464-5116)
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
Car Air Airport
Airline/Flight #
Arrival
Departure
I need driving directions YES NO
I will be staying for the Academy Meeting YES NO
I am willing to share a room at the conference hotel: YES NO
Registration Fees
Registration Fees (includes annual Academy membership fee & most meals from Thursday supper to Saturday lunch.) Select all options that apply.
(pay this only if you are not attending the conference)
Total Fees Owed:
I am paying my fees by:
Checks should be payable to Academy of Process Educators & mailed to:
Dr. Peter Smith 1036 North Niles Ave South Bend, IN 46617
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