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Asilomar Conference

Membership Application (on-line)

Deadline for Registration: November 10, 2009


Instructions: Complete all information; incomplete forms will delay registration. ONE FORM PER PARTICIPANT. Adults only, please. Mail early to ensure your registration. Registration will be accepted on a space-available basis. No on-site registration. Sorry, no refunds; registration may be transferred. Please notify registrar of any changes. Late fee ($10.00) after November 10, 2009.

Today's Date
First Name
Last Name
Female/Male
Mailing Address
City
State Zip___+___
(Area) Home Phone
(Area) Work Phone
Home E-Mail
School
District
Position
Grade Level/Other
SCCRC Membership
Type of Payment
Credit Card
Credit Card #
Expiration(Mo/Day/Year)
Name on Card
Meal Order
If other, explain
Sunday
Accomodation Plan (SEE BELOW)
Confirmed Roommates
*Handicapped (Explain Needs)
Registration Fee
Lodging Fee
Late Fee after 11/10/09 ($10)
Total Fee
Questions/Comments
  

Contact Kathy Noether if confirmation of registration form has not been made within 72 hours.

Kathy Noether, Registrar

Overnight Rates per person: 2 nights lodging + 6 meals (All rooms are non-smoking.)

Rates: per person

Plan A (1 to a room)
Plan B (2 to a room)
Plan C (3 or more)

#1 Historic Rooms:

$335.00
$240.00
N/A

#2 Standard Rooms:

$420.00
$265.00
$225.00

If sending payments by checks or purchase orders, please make payments to: SCCRC-AC and mail to:

Kathy Noether, Registrar
4246 Meg Drive
San Jose, CA 95136

Other information or questions please call Kathy Noether, Registrar, at 408-267-3426 or click on the link above to e-mail.