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
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berg@ics.uwex.edu
© Copyright 2006 Board of Regents, University of Wisconsin
Last updated May, 2006