Please print clearly: Participant Registration Form

Name: ____________________________________________________

Maiden Name: _____________________________________________

Birthday: _____________________

Address: ___________________________________________________

City: _______________________________ State: ______ Zip: ________

School: ______________________
Circle One: MS / JH / HS / CC / COLL / UNIV

Home Phone (______) ______________________ Work Phone (______) _______________________

Email: ______________________________________________________________________________________

** Required Items, all participants must pay **

1 Week

Workshop Registration: Includes workshop syllabus, insurance, registration, and Recreation Center fees.

University Fee:

$110.00

$160.00

Workshop Fee:

$75.00

$135.00

Total

$185.00

$295.00

** $ _______

q CAHPERD Members: Deduct $15 for 1 week or $27 for 2 weeks

Meal Ticket: Includes Sun. & Wed. dinner, M-F lunch

$66.00

$132.00

** $ _______

q Please check here if you are a vegetarian.

Campus User Fee:

Participant Housed On-Campus:

$3.00 / workshop

** $ _______

Participant Housed Off-Campus:

$10.00 / workshop

** $ _______

Housing: Includes Sunday through Thursday night (Two week rate includes weekend. All rates are per person.)

Single:

$140.00

$336.00

$_________

Double:

$100.00

$240.00

$_________

Special Housing Needs:

Extra night stayover (circle): July 8, 10, 14, 15, 21
(Extra nights must be reserved by June 28th. Workshop cannot accommodate early arrivals prior to July 8.)

Single:

$_________

Double:

$_________

Block Classes: Saturday, July 15th: (Select only one.)

q Golf

$25.00

$_________

q Dance

$25.00

$_________

q CPR/First Aid Certificate: Re-certification

$25.00

$_________

q CPR/First Aid Certificate: New Certification

$35.00

$_________

Other Class Fees:

CIF Coaching Certification: Course Materials Fee
(Offered first week only)

$55.00

$_________

Computer Class: Lab Fee
(Offered Week One &endash; 2nd & 4th hour; Week Two 4th hour)

$20.00

$_________

Professional Credit: (4 quarter units per week)

One Week (either wk 1 OR wk 2) course # PE-E600-81

$140.00

$140.00

$_________

Two Weeks course # PE-E600-82

$_________

Social Security Number # ________ - ______ - ________

Parking:

All participants with cars must pay for parking. $4.20/car/week

$4.20

$8.40

$_________

Late Fee:

All payments received after June 12

$20.00

$20.00

$_________

$_________

Credit Card: (circle one) VISA MC DISC AMEX Card # ___________________________________

Signature: _________________________________________________

Expiration Date: _____ / 20_____

All checks should be made PAYABLE TO: CAL POLY FOUNDATION. MAIL TO: Conference Services - California Polytechnic State University - San Luis Obispo, CA 93407. (You need to allow a minimum of one extra day for campus mail.) Phone: (805)756-7600 Fax: (805)756-7601. Workshop registration will not be processed with incomplete payment. Returned checks will be assessed a $35 charge. PLEASE NOTE ** if your fees are paid by purchase order, a copy of the purchase order, with a number, must be received in writing by June 12, 2000, in order to avoid paying the late fee of $20.** Anyone who arrives for check-in after 4 pm on Sunday, July 9, and after 3 pm on Sunday, July 16, will be subject to the late check-in fee of $20. All cancellations and refund requests must be received in writing seven working days in advance of program start date and will be assessed a $40 administrative fee. No shows, and any cancellation received after June 30, will be subject to additional charges as appropriate. The deadline for all refund requests to be submitted to Conference Services, including those for no shows, is August 4.
Workshop housing starts Sunday, July 9, and ends Friday morning, July 21. Two week participants who've not paid to stay the weekend MUST check out at the conference desk, remove all belongings and turn in their keys. Upon return, participants will check into a new room. Participants who do not turn in their keys will be charged for the entire weekend. SMOKING IS PROHIBITED IN ALL BUILDINGS ON CAMPUS, INCLUDING THE PUBLIC AREAS OF THE RESIDENCE HALLS.