LAPDA REGISTRATION

NOTE! Please complete all required questions (marked with an asterisk). If you press submit and the form does not go away, you have not registered! Scroll through the form and find the red notation that you must complete that section. Once your form is complete, press submit. You will be directed to a thank you page if it was successful. Additionally, you will receive a confirmation via email within a few days, please contact the office (802) 479-0900 with any questions. If it doesn't submit, then print it and fax it to 479-0905. Thank you.

You will be required to enter a purchase order number in the billing section below. This is a requirement for registering. Please obtain this number from your school/organization before completing this form.

* 2. First and last name (this will be printed on your name tag and certificate):

* 6. If you answered Teacher above Please specify Grade Level and the Subject that you teach for the Instructors Knowledge.
(If this doesn't apply please put None)

* 8. Home Address:

* 9. Home City, State & Zip code:

* 10. Home Phone Number:

* 11. Work Phone Number:

* 12. Extension:

* 13. E-mail (We will use this to send a confirmation of enrollment and if we need to contact you regarding the course over the summer):

BILLING INFORMATION

* 14. What Organization should we invoice?

* 15. Address:

* 16. City/State/Zip:

* 17. To whose attention?

* 18. Phone number:

* 19. Puchase Order Number (Required. If you are paying yourself just write that in the space):

* 20. Amount of Purchase Order: (Required)

* 21. If graduate/undergraduate credit is available, are you taking this course for credit?

* 22. If so, who should we invoice for the credit?

* 23. NOTE! By submitting this registration, you are agreeing to this policy: I understand that by registering, via e-mail or paper copy, for the program named here, I have made a firm enrollment commitment. No refund will be given if I withdraw 7 days or fewer ahead of the start of the course or other program, or if I fail to attend the sessions. You must SIGN this statement by entering your initials in the space provided.

* 24. Registration Policy * Mandatory - enter your initials
I have read and agreed to the withdrawal/refund policy printed above

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