CT After School Network - Network Trainers

Conference Registration Form

Name:
Organization:
Work Address:
City/State/Zip:	State: Zip:
Work Phone:
Home Phone:
Fax:
Email:

Please choose session numbers from the conference brochure and enter your choice preferences below.


10:45 - 12:15 Session 1	1st Choice	2nd Choice	3rd Choice
1:30 - 3:00 Session 2	1st Choice	2nd Choice	3rd Choice

A first, second, and third choice must be indicated.

Conference registration fee includes: Attendance at two workshops of your choice (based on availability; pre-registration required), continental breakfast, and lunch. Certificates of Attendance will be available for each workshop attended. Prices higher as of March 8, 2010.

$80.00 Connecticut After School Network Professional Member

$125.00 Non-member

$130.00 Conference fee and Individual Professional membership

I would like to pay now using PayPal™
Please invoice me. I will pay later.
Checks payable to: Connecticut After School Network, Inc.

You can also print this page and mail your payment to:
Connecticut After School Network, Inc.
12 Melrose Ave.
Branford, CT 06405

Pre-registration is required. Speakers and workshops subject to change due to unforeseen circumstances. Unfortunately, requests for refunds cannot be honored after the deadline for registration. You can apply for CT After School Network membership by selecting the third button indicating payment for $120 for conference fee and individual membership. If you are paying by check, please include a separate check noting that it is for membership.

For information, contact Connecticut After School Network at 203-483-1846, fax 203-481-7160, or email mwhalen@ctafterschoolnetwork.org.

DEADLINE FOR REGISTRATION: Postmarked by March 19, 2010.