Presenter Registration Form
Presenters receive a complimentary, one-day conference registration. We invite you to attend both days of the
conference for the reduced, presenter rate of $100.00.
Please complete this presenter registration form rather than the general form available in the brochure and
online by Friday, April 17. Refer to the conference website for descriptions so you can indicate your preferences
below. Thank you.
Name:
Conference Fees for Presenters
Title:
Registration for the day of your workshop only (check the day
Agency:
of your workshop) - No fee
Thursday
Address:
Friday
City, State, Zip:
Two-day Registration - $ 100.00
(5/7/15 and 5/8/15)
County/counties Served:
I will not attend other sessions or events on the day of my
presentation.
Work phone:
Cell:
Are you interested in contributing any additional dollars to help
fund conference scholarships for those interested in attending
but unable to meet the full cost?
Yes
No
Donation amount: $
(Scholarship funders will receive recognition both on the website
and in the conference program)
Email:
Concurrent Workshops
If you are registering for the conference, please indicate which
workshops you plan to attend. (Circle only one per session)
Thursday Session A:
A1
A2
Thursday Session B:
B1
B2
Friday Session C:
C1
C2
Friday Session D :
D1
D2
A3
B3
C3
D3
Would you like a vegetarian lunch?
A4
B4
C4
D4
A5
B5
C5
D5
Method of Payment (if registering for two days)
Choose only one:
Check (payable to Teenwise)
Check requisition in process
B6
C6
D6
B7
C7
D7
Yes
List any other dietary restrictions here:
Credit Card
Visa
Mastercard
Card #
Expiration Date:
American Express
-
-
-
-
Signature:_____________________________________
Name, billing address, and zip code for card.
Please indicate if you require any special access accommodations:
Please email or send your completed registration form with payment
(made payable to Teenwise) to lauren@annplans.com or to the
address below by Friday, April 17, 2015:
Teenwise Minnesota
Attn: Conference Registration
1619 Dayton Avenue, Suite 111
St. Paul , MN 55104
Fax: 651-644-1417
Email: lauren@annplans.com
Questions? Please contact David Kurtzon
at 651-289-1383 or david@teenwisemn.org.
Bill me (Choose this option only if your agency requires a
purchase order to make payment.)
Bill my agency using purchase order #
and direct correspondence to the
following staff person:
Name:
Mailing Address:
City, State, Zip:
Phone #: