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Institute Form
Online Individual Registration Form - Fall Institute 2017
(complete a form for each person attending)
First Name:
Last Name:
Address:
City:
State:
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
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.
The check or purchase order will be from:
FORM VALIDATION
Enter the words above:
Enter the numbers you hear:
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.