Registrant Details    ( required fields)

 Name

  

Title/Department

School/Affiliation

Mailing Address 1

  

Mailing Address 2

City

State          Zip       Country 

 

  

Phone (home)

 

Phone (cell/mobile) 

Email
  Will you be attending the conference kick-off session (click for details)?       YES       NO 
     
  Photo Release

We will have a photographer in attendance at the conference. Candid photos will be taken to be used for purposes such as Academy membership brochures, the Academy website, etc. If you object to your image being used for these purposes, please indicate at right.

You may use
my image

   

 Travel Information

I will be arriving by

Air      Car

Airline/Flight #

Airline   Flight #

Arrival

 Date     Time  

Departure

 Date     Time  

I need driving directions          YES       NO 

I will be staying for the Academy Meeting        YES       NO 

I am willing to share a room at the conference hotel:        YES       NO 

   

 Registration Fees

Registration Fees (includes annual Academy membership fee & all meals from Wednesday supper to Friday lunch.)

Note that "double occupancy" means sharing the cost of a room with a roommate rather than buying an extra bed for your own use.

Conference Registration (does not include lodging)   $300
Conference Registration (Kirkwood faculty)    

         (see Al Rowe for payment information)

    
Out-of-Town Conference Registration (Double)   $450

         (includes two nights at hotel - double occupancy)

    
Out-of-Town Conference Registration (Single)   $550

         (includes two nights at hotel - single occupancy)

    
Emeritus Faculty Conference Registration (Single)   $200

         (includes two nights at hotel - double occupancy)

    
Academy Membership Only   $50

         (pay this only if you are not attending the conference)

    
  Extra Hotel Nights ($75 double, $125 single, per night) $

Total Fees Owed:

 $
   

 I am paying my fees by: 

Online Payment Submit your registration and you will have the opportunity to complete your payment online, if you wish to use a credit or debit card (we use PayPal as our payment processor). Note that this option is NOT available to pay for extra hotel nights; you will need to pay by check if you selected that option.
Other arrangements Kirkwood Faculty ONLY
I will mail a check

Checks should be payable to Academy of Process Educators & mailed to:

Dr.  Peter Smith
1036 North Niles Ave
South Bend, IN 46617

 

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