Living Our Civic Values - June 1-2, 2017

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

*First Name:

*Last Name:

*Institution/Organization

*Position/Title

*If faculty, list discipline

*Email:

*Address Line 1:

Address Line 2:

Address Line 3

*City:

*State:

*Zip Code:

*Registration Costs Per Person

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 May 24, 2017. 
   
Registration costs per person:    
$100 both days per person from Campus Compact Member Institution 
$150 both days per person from Non-Campus Compact Member Institution 

$60 June 1st only per person from Campus Compact Member Institution 
$60 June 2nd only per person from Campus Compact Member Institution 

$85 June 1st only per person from Non-Campus Compact Member Institution 
$85 June 2nd only per person from Non-Campus Compact Member Institution

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 May 24, 2017. 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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