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Pre-registration Form for 2008 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 commitment fee of $100 which will be reimbursed to you once you complete the course. This pre-registration form does not officially hold your seat for the course; official registration will occur once the commitment 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.

*On-campus housing is available through a scholarship; please contact Nora Dillon at (570) 945-8555 to reserve your space.

* 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:		*

What is the name of your hometown newspaper?		*

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 FREE; 3 Keystone College Undergraduate Credits $1,125; 3 NEIU-19 CPE Credits $255; 3 Wilkes University Graduate Education Credits $1,035 Watershed Explorers, June 22-27, 2008 (grades K-6) - Previously called Watershed Concepts Astronomy, June 22-27, 2008 (grades 7-12) Forests and Society, July 13-18, 2008 (grades 7-12) - Previously called Forest Stewardship Climate Change and the Energy Challenge, July 20-25, 2008 (grades 7-12)

Which of the following options do you wish to obtain?* Act 48 Hours (FREE) (available for all courses) 3 CPE Credit ($255) (available for Watershed Explorers, Astronomy, Forests and Society, and Climate Change and the Energy Challenge) 3 Keystone College Undergraduate Credit ($1,125) (available for Watershed Explorers & Forests and Society) 3 Wilkes University Graduate Credit ($1,035) (available for Watershed Explorers, Astronomy, Forests and Society, and Climate Change and the Energy Challenge)



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