Please complete the registration form.

Conference Registration Form

Registration deadline: Wednesday, November 3, 2010

Complete the following form and click on SUBMIT to confirm your registration. Be sure to hit the SUBMIT button before leaving this page or your information will be lost.

Contact InformationFirst Name:

Last Name:

Department:

Institution:

Position/role (ex. Department Head, Faculty, Academic Technologist...)

Email Address:

Confirm Email Address:

(Please Note: Your email address is what we use to track your application and participation in the workshop. Be sure to use the same email address in all forms relating to your workshop participation. This email will also be our primary means of communication with you.)

Lodging: Double occupancy rooms will be booked at the Crown Plaza Five Seasons Hotel in Cedar Rapids. Please indicate a preference for a roommate.

If you have no preference or do no need lodging, please indicate that here.

No roommate preference
No lodging required

Meals: Please indicate any meal restrictions or preferences.

None
Vegetarian

Other:

Name Email *Please type the two distorted words into the box below. Separate them with a space. This helps us prevent spam. For more details or help click the question mark.

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