Conference
Registration Form
(Print
out the form and mail in with payment)
_____________________________________________________________________
Miss/Ms./Mr./Dr.
First Name
Last Name
______________________________________________________________________________
Name
on Tag
Title
______________________________________________________________________________
Organization
______________________________________________________________________________
Address
______________________________________________________________________________
City
State
Zip
______________________________________________________________________________
Phone
Fax
______________________________________________________________________________
Email
All
registration fees include the following meals: Breakfast and
lunch on 6/11; Breakfast, lunch and dinner on 6/12, Breakfast
on 6/13.
Apply
a discount of $25 per registration with four or more registrations
from the same organization. If more than one person registers
from the same organization, each person must fill out a registration
form.
______
$115 Early Registration (before
April 15, 2004)
______
$155 Regular Registration (April
15 through May 31)
______
$170 On-site Registration (after
May 31)
______
$60 One-day Registration
for SATURDAY ONLY
______
I am part of a group from the same organization. _____# in
group
______
I am applying for a full or partial scholarship (see attached
application)
______
I am interested in Continuing Education Credits
______
TOTAL AMOUNT ENCLOSED (No credit
cards accepted)
Please
make check payable to: The Institute
for Community Research
Send
to: The Institute for Community Research
ATTN:
Crossroads Conference
2 Hartford
Square West, Suite 100
Hartford,
CT 06106
Other
Preferences
I am
planning on attending dinner on:
_____
Saturday, 6/12 ______ I am a vegetarian
_____
Special needs (list): _____________________________________________
_____
I plan on joining the pre-conference tour of Hartford's neighborhoods
Cancellation
Policy: There will be a $50 fee for all cancellations up to
10 days before the conference begins (May 31, 2004). Cancellations
after May 31 will NOT receive a refund (unless for an emergency).
How
did you hear about the conference?_____________________________________
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