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Pre-registration Form for 2010 Courses

IMPORTANT: PLEASE READ AND FOLLOW DIRECTIONS

Please complete the following information, print the confirmation page that is displayed after you submit this form, and mail it to the address printed on the confirmation page along with your non-refundable registration fee of $200. This pre-registration form does not officially hold your seat for the course; official registration will occur once the $200 fee is received. Cancellations must be made two weeks prior to the start date of the course for a full refund. Failure to attend the course will result in a forfeiture of your fee. Make checks payable to Keystone College/KceeI. Please fill out the registration form and return it with your check. More information will be sent to you in the mail after your registration is received.

* Denotes required fields

First name:		*
Middle initial:
Last name:		*

School District:		*
School:		*
Position Title:		*
Grade Taught:		*

Home Address:		*
Home Address: (2nd line if necessary)
City:		*
State:		*
Zip:		*

Will You be staying on campus?		* (yes or no)

How did you hear about KceeI?		*

Phone:		*
E-mail:		*

Who is your curriculum coordinator?		*

What is your curriculum coordinator's email?

Who is your principal?		*

Which course will you be attending?* (This form is set up to register for one course at a time. Please complete a new registration for additional courses. Priority will be given to teachers of the appropriate grade level listed for each course.) Week-long Courses Option of receiving Act 48 hours; NEIU-19 CPE Credits; 3 Keystone College Undergraduate Credits; or 3 Wilkes University Graduate Education Credits Watershed Explorers, June 20-25, 2010 (grades K-6) *Geology of Northeast PA,* July 11-16, 2010 (grades 7-12) Flora and Fauna of PA, July 18-23, 2010 (grades K-12) Climate Change and the Energy Challenge, July 25-30, 2010 (grades 7-12)

Which of the following options do you wish to obtain?* Act 48 Hours (FREE + $200 KceeI Registration fee) 3 CPE Credit ($285 +$200 KceeI Registration fee) 3 Keystone College Undergraduate Credit ($1,170) 3 Wilkes University Graduate Credit ($1,110 + $200 KceeI Registration fee)

Breakfast and lunch are provided and attendance is required On-campus housing is available through a scholarship; please contact Nora Dillon at (570) 945-8555 to reserve your space.

* Denotes required fields