Increasing Your Impact as an Instructional Coach (Grades K-6) – Eastern, on January 7   (AIE6F1-EAS)
CC

Standard Price: $395.00

Group Price: $375.00
Register 3 or more to this seminar at the same time to receive discount.

Group registration?       List additional registrants on a copy of this form.

Basic Information

Grade Level:____________Job Function or Subject:_____________________________________________________

Priority ID Code

Important! To expedite your registration, please fill in your Priority ID Code from your brochure, even if it was not addressed to you.
It is the six digit number on the mail label next to the word "PRIORITY ID CODE".

Priority ID Code on my brochure is:_________________________

  I don't have my brochure with me           I did not receive a brochure

Your School

School Name________________________________________________School Phone:(_____) __________________

School Address: ____________________________________________________________________________________

School City/State/Zip: ________________________________________________________________________________

Contact Information

(Required) Email Address:__________________________________________Home Phone:(_____) ______________

Home Address:_____________________________________________________________________________________

Home City/State/Zip:_________________________________________________________________________________

Payment Method:

Credit Card Payment:    Visa   Mastercard   Discover   American Express     

Card Number:__________________________________________________CVV Number (on back of card):_________

Cardholder's Name:________________________________________Expires:________Billing Zip Code:_________

Purchase Order Payment

Purchase Order Number:______________________________________________________