Online Individual Registration Form - Fall Institute 2017

(complete a form for each person attending)

First Name:

Last Name:

Address:

City:

State:
State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY

Zip:

County:

Phone number with area code:

Organization Name:

Position:

Email:

(PLEASE NOTE: confirmations and attendance certificates will be sent by email only.)

REGISTRATION FEES

(Check all that apply)

Thursday, September 21, 9:00 - 4:00 pm

(Space is limited for all pre-institute events. There is a $10 late fee for registrations received after 8/31.)

A. The Power of Peers: Using peer-mediated strategies and embedded routines within routines to foster and support children’s social emotional development.

$45

B. Child Care Grant and Proposal Writing

$45

C. Shaping Healthy Children with Nature Explore and Farm to Early Care

$45

D. Winning Ways to Becoming a Better Supervisor

$45

E. Coming to Our Senses: Applying Sensory Processing Knowledge to Your Everyday Practice

$45

I am not attending a pre-institute event

Friday and Saturday, September 22-23

Registered on or before August 31

Registered after August 31

	1 DAY-FRIDAY	1 DAY-SATURDAY	BOTH DAYS		1 DAY-FRIDAY	1 DAY-SATURDAY	BOTH DAYS
Member	$70	$40	$100		$110	$90	$145
Non-Member	$115	$115	$175		$150	$150	$225
Student	$55	$45	$80		$75	$65	$100

If you are a member or employee of any of the following co-sponsoring organizations, you are eligible for the member rate (check all that apply)

Iowa AEYC

IHSA

MEALS - All attendees will receive one meal each day of attending the Institute

Special dietary needs (check all that apply):

Gluten free

Dairy free

Vegetarian

Other (please specify):

I plan to attend the Iowa Head Start Association Meeting on Friday - meal provided (no charge)

FORM OF PAYMENT

Check

Purchase order (fax to 515-331-8995)

Credit card. These payments will be handled through Pay Pal.

FORM VALIDATION

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If you would like a copy of your filled out registration form, please print this page before clicking submit. To total your fees and receive payment instructions, click the submit button below.