May 30, 2013 PASSHE Service-Learning Course Development Workshop

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

*First Name:

*Last Name:

*Institution

*Position/Title

*If faculty, list discipline

*Have you taught Service-Learning before:

*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-------------------------------------------

Registration Deadline is May 20, 2013. Please follow the instructions below to complete your registration.  We do not have the ability to accept electronic payments.   
    
Registration costs per person (includes lunch & refreshments):    
    
$40 Per participant from Campus Compact member institutions    
$100 Per participant from Non-Campus Compact institutions     
    
Please send payment AND a copy of registration form (print this page)by May 24th to:    
    
Pennsylvania Campus Compact    
28 South Dewberry Street, Box 8
Harrisburg, PA  17101
    
All checks must be received by May 24, 2013. Checks can be made payable to Pennsylvania Campus Compact.    

Cancellations made before May 23, 2013 will receive a refund of their registration.  NO refunds will be made after May 23, 2013.  
    
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. 
 
Your registration is NOT complete until you hit the submit button.

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