SIP2011Registration
Exit this survey

1. REGISTRATION FORM

Please complete the requested information below and submit the information or print it out and return the registration form to American Indian Support Project (AISP), Psychology Department, Utah State University, 2810 Old Main Hill, Logan, UT 84322-2810.

1. Please enter your demographic information

Please enter your demographic information Name
Address
City, State, Zipcode
Email Address
Work Phone Number
Home Phone Number

2. Tribal Affiliation

Tribal Affiliation

3. Do you have a college degree?

Do you have a college degree? Yes

Degree

4. If you are a student, where are you attending?

If you are a student, where are you attending?

5. Degree Program

Degree Program

6. Year in Program

Year in Program

*
7. 8. Do you plan to attend the Bear Lake Retreat?

8. Do you plan to attend the Bear Lake Retreat? Yes

8. If yes, check your accommodation preference:

If yes, check your accommodation preference: Retreat Center at Bear Lake

Horse Camp in Logan Canyon

On your own

9. Sleeping space at the Retreat Center is assigned on a first-reservations-received basis. The Retreat Center is available for Friday after 4pm, Saturday, and Sunday until 2:00 pm. Sleeping space at the Retreat Center is assigned on a first reservations received basis.

The Horse Camp has unlimited camping space and camping equipment will be provided upon request.

Please submit or return this form by April 26, 2011 to:

AISP Office
Psychology Department
Utah State University
2810 Old Main Hill
Logan, UT 84322-2810
Phone (435) 797-1465
Email: cbarcus@cc.usu.edu
Email: gayle.morse@usu.edu

If you are a student and need financial assistance for travel or help with accommodations in Logan for the convention, please contact Carolyn Barcus or Gayle Morse. Call 435-797-1465 for Carolyn or 435-797-5547 for Gayle.

Estimated Arrive Date:

Sleeping space at the Retreat Center is assigned on a first-reservations-received basis. The Retreat Center is available for Friday after 4pm, Saturday, and Sunday until 2:00 pm. Sleeping space at the Retreat Center is assigned on a first reservations received basis. The Horse Camp has unlimited camping space and camping equipment will be provided upon request. Please submit or return this form by April 26, 2011 to: AISP Office Psychology Department Utah State University 2810 Old Main Hill Logan, UT 84322-2810 Phone (435) 797-1465 Email: cbarcus@cc.usu.edu Email: gayle.morse@usu.edu If you are a student and need financial assistance for travel or help with accommodations in Logan for the convention, please contact Carolyn Barcus or Gayle Morse. Call 435-797-1465 for Carolyn or 435-797-5547 for Gayle. Estimated Arrive Date:

SIP2011RegistrationExit this survey