Form

African American Students in Urban Schools: Critical Issues & Solutions for Achievement
Equity Assistance Center
May 14-16, 2013

Welcome to the online registration for our May 2013 conference in Denver, Colorado. All correspondence concerning this conference will be sent to the address you provide below. For more conference information, please visit www.MetroState-EAC.org Thank you and see you in May!

** Required Field

Personal Information:

Full Name**:

Title**:

Organization**:

Contact Information:

Street Address**:

City**:

State/Province**:
(Enter N/A for foreign address)

Country**:

Zip/Postal Code **:

Phone**:

Fax**:

E-mail**:

If registering additional people, please provide names:

Conference Registration Fee:

I am registering for:
 * Early Bird Rate of $350 is valid January 15-March 15, 2013 only; Full Registration of $400 is valid March 16-April 30, 2013; Daily Rate is $150

Select registration **:

Total Conference Registration Fee: $

Dietary Restrictions:

Vegetarian:

Diabetic:

Food Allergy:

Other:

Emergency Information

Additional Information

Liability Wavier**:

Please sign your name electronically in the space provided below. By signing, you are agreeing and acknowledging that you are a willing participant at this conference and you are assuming responsibility for your own well-being.

If you would like to pay with a check, please make it payable to:

Equity Assistance Center
Campus Box 63-A
P.O. Box 173362
Denver, CO 80217-3362