Capacity Building Training
Capacity Building Training Registration
March 5, 2013
8:00-12:00
Kings Inn Hotel & Conference Center
Pierre, SD
*
1
. Name
Name
*
2
. Work Phone
Work Phone
*
3
. Partnership/School/Coalition/Agency Name
Partnership/School/Coalition/Agency Name
*
4
. Address
Address
*
5
. City/State
City/State
*
6
. Zip Code
Zip Code
*
7
. Email
Email
*
8
. Home/Cell Phone (in case of inclement weather)
Home/Cell Phone (in case of inclement weather)
*
9
. What kind of scholarship are you requesting? Please check all that apply.
What kind of scholarship are you requesting? Please check all that apply.
Hotel Stay
Round Trip Mileage
$12 per diem
Substitute Teacher Fee
None
*
10
. Will you be staying for a free lunch that will be served immediately following the training?
Will you be staying for a free lunch that will be served immediately following the training?
Yes
No
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