Childhood Mega Conference Registration Form

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2011 Mega Conference Registration -- Page 1
March 10 & 11
Please use this form ONLY for Registration
Must submit BOTH page 1 and page 2       
Registration Deadlines: March 1 at lowest rate
Final Registration Deadline: March 8 at higher rate
Name of Program or Individual _______________________________________________________________________
Mailing Address ___________________________________________________________________________________
Street/PO Box/Other
City/State
Zip Code
Contact Person _____________________________________Position/Title____________________________________
Contact Person Email _______________________________________________________Day Phone_______________
Please Print Clearly -- Registration Confirmation Will Be Emailed ONLY
Program: ___Head Start
___Family Child Care
___Day Care Center
___ECFE
___ECSE
___Learning Readiness
___Other, please specify______________________________________________________________________
Note to Northern MN Child Development Advisory Council (NMCDAC): You will be billed for any additional
registrations over the number you have already confirmed and paid for on your Letter of Commitment.
Conference Registrations
Note Deadlines – Refer to “Mega Conference Registration Fees”
______person(s) Thursday, March 10 ONLY X $140 (by 3/1) $150 (by 3/8)
= $____________
circle correct daily fee
______person(s) Friday, March 11 ONLY X $140 (by 3/1) $150 (by 3/8)
= $____________
circle correct daily fee
______person(s) X $270 (by 3/1) $290 (by 3/8) ENTIRE 2-day conference
= $____________
circle correct conference fee
TOTAL REGISTRATION AMOUNT $_________________
If mailing please postmark two (2) days prior to deadline date!!
Payment Information
___Paid on Letter of Commitment (NMCDAC) CDTP will bill for any additions
___Check attached (made payable to CDTP) in the amount of $_______________
___Bill to the above agency (Purchase Order attached or PO # ____________) the amount of $____________
Registration is non-refundable, therefore all Purchase Orders must be honored.
__________________________________________________________________________________________
Return registration pages 1 & 2 to Zoe Ann Wignall Child Development Training Program,
Bemidji State University #35, 1500 Birchmont Drive NE, Bemidji, MN 56601
OR
Fax pages 1 & 2 to Zoe Ann Wignall at 218-755-3787       
Questions: Zoe Ann @ 218-755-3779 or 888-234-1305 or [email protected]
OFFICE USE ONLY: Date received_______________ Paid _______________
Billed______________
2011 Mega Conference Registration --Page 2
Please use this form ONLY for registration
MUST SUBMIT BOTH PAGE 1 AND PAGE 2
Be sure to indicate the days you will be attending.
Both sides of this form must be received by March 1 for lowest rates.
Please Reproduce This Side of the Registration Form if You Need More Room
Agency/Program/ Individual ___________________________
Attendance
Name of Participant
Please mark all that apply:
Thurs. Friday
Register
For Credit
CDA
Renewal
Presenter
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Please complete and send or Fax page 1 and 2
10/11
BSU
CDA
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