Process Education Conference 2015

Remember, the conference is scheduled for June 25-27, 2015

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 & Video Release
We will have a photographer/videographer in attendance at the conference. Candid photos and video 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

Meals & Menu Selection

Please count me in for the following meals:

Thursday reception Friday lunch Friday dinner* Saturday lunch

I require a vegetarian option for my meals

* Note that there is a possibility that Friday's dinner will take place off-campus. We will let all registrants know as soon as possible.

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

VSU Faculty/Staff Conference Registration (VSU is paying for you!) $0

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).

VSU Faculty/Staff Submit your registration; your fee has already been paid by VSU.

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?

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