Mid-Level Institute 2012: Building Blocks for Your Future

Registration Form

For any further information please feel free to email Kristin Murphy at kristinconti@yahoo.com

Participant Information

* First Name

* Last Name

* Name on Name Tag

Title

* Institution

* Address 1

Address 2

* City

* State

* Postal Code

* Business Phone

Fax

* E-mail Address

Please list any dietary retrictions or special requirements you may have.

* Highest Level of Education:

* Years as a full-time professional:

* Area of Responsibility (i.e. operations, training, housing, etc)

Please upload a copy of your most up-to-date resume here. (you may also email a copy to kristinconti@yahoo.com)

* Do you plan on staying in the hotel the night before? (Note: you will need to make your own reservation.)

Yes

Not sure

Will you need a parking pass for campus?

Yes

Institutional Information

* Institutional Housing Capacity (Please tell us how many students live on your campus)

* Institutional Setting (Please tell us if your institution is an urban, suburban, or rural setting)

Conference Cost

* Number of NEACUHO members attending ($50 registration fee)

* Number of Non-NEACUHO members attending ($85 registration fee)

* Please indicate your method of payment:

Paypal

Check

If you would like to use paypal, please indicate the name of the individual who will be making the payment on your behalf, as it is printed on the credit card. You will have the option to do so after you click "Continue" on this form.

Please make checks payable to: NEACUHO. NEACUHO's tax ID is 22-2505-432. Please make every effort to mail in your payment prior to the conference to

Kim Schmidl-Gagne
NEACUHO Treasurer
Keene State College
229 Main Street:

Check Payment has been mailed

Check Payment has not been mailed but will be prior to the conference

Check Payment will be presented the day of the conference

Financial Guidelines
- Substitutions will be accepted.
- Cancellations of registration made earlier than 14 calendar days prior to the conference date may be refunded for extenuating circumstances (i.e. family emergencies, urgent campus situation).
- Requests for refunds must be made in writing to the Treasurer or Committee Chair and verified with a CHO signature.
- Individuals/institutions making cancellations after 14 calendar days prior to the conference date will still be held responsible for registration costs.

* Indicates Response Required