SMCAA Affiliate Membership Application

Instructional Leadership

Online Registration
June 20-21, 2023
Old Kinderhook Lodge, Camdenton, MO,

Date:
June 20-21, 2023

Location:
The Lodge at Old Kinderhook
678 Old Kinderhook Drive
Camdenton, Missouri 65020

Cost:
Member District $300 /individual
Non-member District $400/individual

To register simply fill out and submit the form below.
Each registration must include a valid P.O. number.

Registration Deadline:
June 9, 2023

SMCAA Cancellation Policy:

No refunds or cancellations after May 22, 2022

Unless indicated, ALL FIELDS ARE REQUIRED
You will receive an e-mail confirmation of your registration details, please keep this e-mail for your records.
Attendee Information
Name

First NameLast Name
School Building*
School District*
Title*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Breakouts

Distirct/Building LeadersInstructional Coaches
SMCAA Member Status*

SMCAA Member District $300Non-Member $400
Billing
Amount to Bill
Billing*

Bill me now (before June 30)I prefer delayed billing (after July 1)
Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Purchase Order#*
Enter "n/a" if not applicable
By submitting this registration form you hereby agree to give permission to SMCAA, granting full right of ownership and free use without restriction of photographs of yourself, for any and all purposes in promoting education in Missouri, including but not limited to printed publications, websites, and electronic newsletters.

Cancellation Policy:
Due to a limited number of participants that can attend this workshop, cancellations will not be refunded 30 days prior to the date of the workshop. Your district may send another staff member in your place, if you are unable to attend after the cancellation date. Please submit any substitutions to Julie Riley at jriley@smcaa.org or by calling 573-635-2299.
Should be Empty:

Instructional Leadership

Attendee Information

Billing