Literacy Essentials Conference
Payment by eCheck, Mastercard, or Discover ONLY
Name
First Name
Last Name
Phone Number (Best way to be contacted)
-
Area Code
Phone Number
Please Indicate
Home
Work
Cell
E-mail
Confirm E-mail
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Registration Type
Please Select
Early Bird Registration by February 26, 2018, $80.00
Registration after February 26, 2018, $90.00
Undergraduate (CCSU) (with completed Alumni Form) $20.00
Undergraduate Students must complete
Alumni Award Form (attached)
Will you be attending the Dessert with Authors? Please note, this portion of the program is an additional $10.00.
Yes
No
CCSU Student
Please Select
Yes
No
To avoid duplication, please indicate:
CCSU ID
OR
Date of Birth
-
Month
-
Day
Year
Date Picker Icon
School/Employer
Registration Fee (includes breakfast and lunch)
*
Please Select
$80 - Early Bird Registration by February 15
$90 - Registration after February 15
$80 - Group Rate (6 or more) per person
$50 - Undergraduate Student
Submit
Should be Empty: