April 14, 2016 - ENGAGE! Out of the Classroom, into the Community

---------------------------------------------Section I: Registrant Information----------------------------------------------

*First Name:

*Last Name:

*Institution

*Position/Title

*If faculty, list discipline

*Email:

*Address Line 1:

Address Line 2:

Address Line 3

*City:

*State:

*Zip Code:

*Phone Number:

Dietary Needs

If Other selected above, please describe:

Other Special Needs:

-------------------------------------------Section II: Payment Information-------------------------------------------

We do not have the ability to accept electronic payments. Please follow the instructions below to complete your registration and submit payment by March 31, 2016.    
    
Registration costs per person (includes a continental breakfast and lunch):    
    
$40 Per participant from Campus Compact member institutions    
$60 Per participant from Non-Campus Compact institutions     
    
Please send payment AND a copy of registration form (print this page) to:    
    
Pennsylvania Campus Compact    
28 South Dewberry Street, Box 8
Harrisburg, PA  17101
    
All checks must be received by April 7, 2016. Checks can be made payable to Pennsylvania Campus Compact.    
    
Questions regarding payment can be directed to Michele Lowrey    
at mlowrey@paccompact.org or 717-796-5072 ext. 1.

Final Confirmation

Prior to hitting the submit button below, please print this page for your records and include with your payment. 
 
Your registration is NOT complete until you hit the submit button.

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