Registration Form

Presidents Institute • Chief Academic Officers Institute • Foundation Conversation • Workshops and Other Events •

2004 Teaching and Learning Mentors Institute

Deadline for Conference Registration: July 10, 2004

Instructions:

Use only one registration form per institution.
Compute your registration fees according to the chart below.
Make checks payable to the Council of Independent Colleges.
Mail printed form and check to: Teaching and Learning Mentors Institute, CIC, One Dupont Circle, Suite 320, Washington, DC 20036-1110.
Fax: 202-466-7238; e-mail: conferences@cic.nche.edu
(E-mail confirmation will be sent to you upon receipt of your registration.)

College/Institution's Name and Address
*Institution:
*Address:
*City, State, Zip:
*Phone #:
*Fax #:


Main Registrant
*Name:
*Title/Department:
Direct Phone #:
E-mail:

Additional Registrants
1.	Name:
	Title/Department:
	Direct Phone #:
	E-mail:

2.	Name:
	Title/Department:
	Direct Phone #:
	E-mail:

3.	Name:
	Title/Department:
	Direct Phone #:
	E-mail:

4.	Name:
	Title/Department:
	Direct Phone #:
	E-mail:

5.	Name:
	Title/Department:
	Direct Phone #:
	E-mail:

If you have more than five additional registrants, please list their name, title, direct phone and e-mail here:

Institution's Registration Fees
*Member Rates:	First registrant @ $225
*Member Rates:	additional registrants @ $205 each	$
*Nonmember Rates:	First registrant @ $275
*Nonmember Rates:	additional registrants @ $255 each	$
		Total $

Special Needs:

Cancellation Policy: Refunds will be made in full (less $25 processing fee) for cancellations received more than 10 business days prior to the workshop for which you have registered. Refund requests received between 5 and 10 business days of the start of the workshop incur a charge equal to 25% of the total registration fee. Requests received less than 5 business days prior to the start of the workshop are ineligible for a refund. Requests must be made in writing (may be faxed to 202-466-7238). Refunds will be issued after the workshops. Registrations are transferable within an institution.