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Writing and Assessment Retreat - November 14, 2016
---------------------------------------------Section I: Registrant Information----------------------------------------------
*First Name:
*Last Name:
*If faculty, list discipline
*Address Line 1:
Address Line 2:
Address Line 3
*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 October 21, 2016.

Registration costs per person (includes light breakfast and lunch):

$40 per participant from Campus Compact member institutions
$100 per participant from Non-Campus Compact member 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 October 21, 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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