11th Annual Faculty Learning Community Developers’ and Facilitators’ Summer Institute

June 23-26, 2010

Kellogg West Ranch at California Polytechnic State University
Pomona, (Southern) California

Conference Only Registration Form

Contact info

First Name:

Middle Name/Initial:

Last Name:

Nickname for Nametag:

Department:

Institution:

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Country:

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Emergency contact info

Contact Name: (include country code if outside US)

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Contact Email:

Special requirements

Sign Interpreter
Wheelchair Access

Other:

Meals:

No Beef
No Poultry
No Fish
No Pork
No Dairy Products
No Eggs

Registration Fee

Individual registration: $250.00

Billing

Check (US funds only, please, payable to IATS)

IATS’s Federal ID Number is 25-1741294. Please mail a printout of the completed form along with your check to:

International Alliance of Teacher Scholars, Inc. (IATS)
PO Box 88-1239
Los Angeles, CA 90009

Visa
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Credit card details

(Note: If you do not wish to submit your credit card information online, you may print a copy of this completed form, write in your credit card information, sign it, and mail it to the address above.)

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(if mailing):
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My billing address is the same as the one above (otherwise, complete this section)

First Name:

Last Name:

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State/Prov.:

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STOP! Before you submit this form, please review your information, and then print a copy for your records.

International Alliance of Teacher Scholars

Twenty-Two Years of Presenting the Scholarship of Teaching and Learning