Regsiter for a BCIP Event
Name: First and last; please submit separate forms for each registrant.
School District:
Mailing Address:
City: State: NJ PA DE Zip:
Phone: Fax: Email:
Note: A confirmation letter will be sent to your email address or fax number.
If your district is a participating BCIP district, there is no cost to attend BCIP workshops. Please select "BCIP Partner District" in the Payment Method box.
Payment method? BCIP Partner District Purchase Order Check Choose Payment Method Credit Card
*Purchase Order # District/Organization Name: *Credit Card: Choose Card Type Visa MasterCard American Express Discover Number: Expiration Date: Name on Card: Same as above Billing Address: Same as above City: State: NJ PA DE Zip: *Check/Money Order# Make Payable to: Educational Service Unit, BCSSSD Mail to: Rowan University/CPCE, 201 Mullica Hill Road, Glassboro, NJ 08028
*Purchase Order #
District/Organization Name:
*Credit Card: Choose Card Type Visa MasterCard American Express Discover
Number: Expiration Date: Name on Card: Same as above Billing Address: Same as above City: State: NJ PA DE Zip:
Number: Expiration Date:
Name on Card: Same as above
Billing Address: Same as above
*Check/Money Order#
Make Payable to: Educational Service Unit, BCSSSD Mail to: Rowan University/CPCE, 201 Mullica Hill Road, Glassboro, NJ 08028
Choose Workshop(s)
Summer Institute on Inclusion $100/day or $200 for all 3 days!
Grade Level: Pre-School - K Pre-School - 5 6-12
June 24, 2009
June 25, 2009
June 26, 2009
SUBMISSION OF THIS FORM DOES NOT GUARANTEE YOUR SPOT. PAYMENT OR PURCHASE ORDER MUST BE RECEIVED WITHIN 21 DAYS.
