Sixth Annual MIDWEST BRAIN & LEARNING INSTITUTE
One form per individual please.

Name:
Position/Job Title/Grade Level:
School/Agency/Organization:
Address: City:
State: Zip: E-mail:
Home Phone: Work Phone:
Do you wish to have your name and contact information published to an Institute networking list?
yes: no:
Please register me for:
_____ Midwest Brain & Learning Institute -- $450.00  
  ____ I am one of 5 people attending from my district
10% discounted rate of $405.00
  
_____ Early Bird Registration -- $395.00  
  ____ I am one of 5 people attending from my district
10% discounted rate of $355.00		  
_____ Post Institute Session on Friday morning -- $35.00 -- Classroom Practice:
"Project Zero: Artful Thinking"		  
  ____ $35 fee waived because I am paying tuition for 2-credit course
Total Amount enclosed: $________________ P.O.#________________  
  ____ I prefer vegetarian meals.

Make checks payable to Hope College and return registration form(s) and payment by May 15, 2006 to:

Dana VanAmberg 1-877-702-8600, ext. 4107 (toll free #)
Ottawa Area ISD Fax: 1-616-738-8945
13565 Port Sheldon Road  
Holland, MI 49424 dvanambe@oaisd.org
1-877-702-8600 ext. 4107  
   

One registration form per individual.

Please duplicate registration form if additional forms are needed.