Asilomar Conference

	Click on logo for directions to Conference Center Kathy Noether, Registrar No On-Site Registration Registration Deadline: November 10, 2009 Today's Date: _________________________ Instructions: Complete all information; incomplete forms will delay registration. One form per participant. Assignments are made only when registration AND full payment are received from the 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. Please print clearly! Print your name as you wish it to appear on your name badge. Name _________________________________________________________ F___ M ___ Mailing Address___________________________________________________________ City________________________________________ State _______ Zip ______+______ Home Phone_________________________ Work Phone __________________________ E-Mail___________________________________________________________________ District ________________________________School ____________________________ Position ______________________________ Grade Level _________ Other __________ SCCRC Membership ______ new ______ renewal ( ) Check (payment in full to SCCRC-AC) ( ) Purchase order enclosed (NO requisition.) Must have copy of PO, not just number. ( ) Credit Card. We accept VISA, Mastercard, Discover, American Express CREDIT CARD #_____________________________________________Exp Date __________ Name on card__________________________________Signature______________________________ Mail to: SCCRC Asilomar Conference Registrar: Kathy Noether, 4246 Meg Drive, San Jose, CA 95136 Other information or questions, please call Kathy Noether, registrar H: 408-267-3426 F: 408-448-0447 E: knoether@aol.com Meal Order Check Day (s) Attending Meals/Fees Prices _____ regular meals _____ Friday Friday Dinner $18.50 ________ _____ vegetarian meals _____ Saturday Saturday Breakfast $10.50 ________ _____ other (explain needs) _____ Sunday Saturday Lunch $12.50 ________ __________________________   Saturday Dinner $18.50 ________ __________________________   Sunday Breakfast $10.50 ________ __________________________   Sunday Lunch $12.50 ________ _____ Sunday Dining Room       _____ Sunday Box Lunch   *Meal Order Total: $_____________             SCCRC Member $75.00 ________     Non-Member/Guest $115.00 _______     Registration ($75)+SCCRC/CRA Membership ($40) $115.00 _______     *Meal Order Total (from above) $_____________     Asilomar Day Use - NOT OPTIONAL - $30 ___ $30.00___     Late Fee after Nov. 10, 2009 ($10) $10.00 ________             TOTAL FEE $ ___________