CALIFORNIA P-16 COLLABORATION & STUDENT SUCCESS CONFERENCE Application Form

(Please fill this out as you would like it to appear on your name tag.)

First Name: Last Name:

Title:
Institution:
Mailing Address:
City: State: Zip:
Daytime Phone: Fax:
Email:

CONFERENCE MEALS:

The conference includes complimentary meals.
Continental Breakfast
Buffet Lunch

Will you be attending the reception?
Yes

SPECIAL NEEDS:

Are you a vegetarian?
Yes

Do you have special access needs?

REGISTRATION FEES (Deadline: June 15, 2008):
$75 Presenter

Other team members:
$100 General
$40 Student
$75 CSULB, LBCC, LBUSD faculty and staff

Total Registration Fees: $ .

Method of payment:

I am mailing a check made payable to: ARCHES -- please provide check #.
I am mailing a Purchase Order from my school district -- please provide purchase order #.


Please mail a copy of this registration form with your check or purchase order to:

Vicki Lovotti
Administrative Associate
California Education Round Table Intersegmental Coordinating Committee
560 J Street
Suite 290
Sacramento, CA 95814

FAX (916) 327-9172

Registration Deadline: June 15, 2008.

(Print out this form and save a copy for your records BEFORE you hit submit.)
Questions? Phone: (916) 324-8593, Email: vlovotti@cde.ca.gov