Conference Registration

Name:

Organization:

Address 1:

Address 2:

City:

State:

Zip:

Phone (w):

Phone (h):

Fax:

E-mail Address:

How did you learn about the conference? (please check all that apply)
mailed invitation
emailed invitation
enews item
school/teacher invitation
flyer from library/community center
media advertisement
other

I will be attending:
October 23
October 24
Both

Do you have special dietary needs? YesNo
If yes, please list here:

Other accommodations?

* I have a child who has: (please check all that apply)
Title I services*
Individualized Education Plan (IEP)
Parents As Teachers (PAT) enrollment*
Home Instruction for Parents of Preschool Youngsters (HIPPY) enrollment*
Free/Reduced lunch*
n/a

* I have a child who is going to: (please check all that apply)
Head Start*
other pre-school
kindergarten
elementary school
middle school/junior high school
high school
n/a

Hotel accommodations, mileage, and childcare stipends will be provided for eligible parents. Overnight accommodations will be provided for eligible parents traveling more than 90 miles one-way. Mileage will be provided for eligible parents traveling more than 70 miles one-way.

Please answer the following questions only if you have selected any of the items indicated by an asterisk (*) above:

Do you need a hotel room for Thursday, October 23? If yes, PACER will contact you.YesNo
Please note: the deadline to request hotel rooms was Oct 9th. Rooms will be provided based on availability. A PACER staff member will contact you.

I would like to request a stipend for: Child Care Travel

How many miles (one-way) will you be traveling?