Measuring Community Engagement Workshop

Measuring Community Engagement Workshop - May 31, 2012

---------------------------------------------Section I: Registrant Information----------------------------------------------

*First Name:

*Last Name:

*Institution

*Position/Title

*Email:

*Address Line 1:

Address Line 2:

Address Line 3

*City:

*State:

*Zip Code:

*Phone Number:

Dietary Needs

If Other selected above, please describe:

Other Special Needs:

-------------------------------------------Section II: Payment Information-------------------------------------------

We do not have the ability to accept electronic payments. Please follow the instructions below to complete your registration and submit payment by May 11, 2012.

Registration costs per person (includes lunch):

$50 Participants from Pennsylvania Campus Compact member institutions
$75 Participants from non-member institutions

Please send payment and copy of registration form (print this page) to:

Pennsylvania Campus Compact
28 S. Dewberry Street, Box 8
Harrisburg, PA 17101

All checks must be received by May 11, 2012. Checks can be made payable to Pennsylvania Campus Compact.

Questions regarding payment can be directed to Michele Lowrey
at mlowrey@paccompact.org or 717-796-5072 ext. 1.

Final Confirmation

Prior to hitting the submit button below, please print this page for your records and include with your payment.

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