FACE IN THE ROCK TEACHER WORKSHOP

REGISTRATION FORM ~ Sept. 19-20, 2003

Name: __________________________________________________________

Home Phone: ______________________________

School Mailing Address: ______________________________________________

_________________________________________________________________

Subject(s) Taught: _________________________________________________

Grade(s) Taught:____________________________

School Phone: ________________________ School Fax: __________________

Email Address: ____________________________

Check day(s) you will attend: ____ FRIDAY ____SATURDAY

Check if you are interested in registering for one university credit:
_____ MTU ______ NMU

Amount Enclosed: _______ (Make checks payable to CCISD)

PERMISSION: I give permission for the Western U.P. Center for Science, Mathematics and Environmental Education to photograph __________________________ (participant's full name) to use in publications, electronic media, presentations and demonstrations and to use my name if pictures are published. In addition, I give permission for any original work produced as a result of my participation in Western U. P. Center programs to be published in some format by the Western U. P. Center.

Send registration form and payment by Friday, September 12 to Loret Roberts, Western U.P. Center, P.O. Box 270, Hancock, MI 49930.

NO REFUNDS AFTER SEPTEMBER 12.