Workshop Registration Form

REGISTRATION FORM

VIDEOCONFERENCING ORIENTATION SESSION(S)

I am registering for the:
(please circle one)

2-hour session 4-hour session 6-hour session 8-hour session

Each person from your organization must register. Please make copies of this form and submit one form for each participant. We ask that one Contact Person for your organization be named who can work with us prior to and during the session(s) period. The Contact Person will help coordinate the registration process, distribute materials to participants, and provide site support for the session(s). If the Contact Person also attends the session(s), then the Contact Person must register as a participant.

Participant Information

Name:_______________________________________________________________

Position:______________________________________________________________

Telephone:________________ Email:__________________ Fax:_________________

Organization's Name:____________________________________________________

Department/Unit:_______________________________________________________

Address: (room, building, etc):_____________________________________________

City________________________________ State__________ Zip_______________

Contact Person

Name:______________________________________________________________

Telephone:_______________ Email:__________________ Fax:_________________

Site(s) to be used during the session(s):_____________________________________

Will Contact Person also be a Registered Participant? Yes_______ No_______

Participant Background Information

Professional Background: _____________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Experience with Distance Education:______________________________________________
_________________________________________________________________________
_________________________________________________________________________

Reason for Attending the Workshop:_____________________________________________
_________________________________________________________________________
_________________________________________________________________________

Special Needs:______________________________________________________________

Fee

By registering for this session(s), participants agree to the following:
The fee for the sessions is $495 per person. There is a 15% discount when five or more are registering from a single organization. The fee covers tuition and materials only. Line, bridge or site charges are not part of the fee and will be a separate cost to the organization. No travel, room or board are included. A $50 per person charge will be assessed for any cancellations received, in writing, less than ten (10) days in advance of the scheduled session(s). Participants and/or their organization are responsible for any additional costs which may occur at their own site.

Enclose payment with registration. Make check payable to: Instructional Communications Systems, UW-Extension


1-4 people attending from this organization:	___________	(total number of people)
2 hr=$400 / 4hr=$425 / 6 hr=$450 / 8 hr=$495	x $_________	per person
Total Amount Enclosed:	$___________


Or, for the Discount Rate:
5 or more people attending from this organization:	___________	(total number of people)
2 hr=$340 / 4 hr=$361.25 / 6hr=$382.50 / 8 hr=$420.75	x $_________	per person
Total Amount Enclosed:	$___________

Please return completed forms and your payment to:

Dr. Rosemary M. Lehman
Instructional Communications Systems
University of Wisconsin Extension
The Pyle Center
702 Langdon Street
Madison, WI 53706

©2002 by the Board of Regents, University of Wisconsin
Last Updated January, 2002
berg@ics.uwex.edu