Sowing Change - February 23, 2018 @ Susquehanna University

---------------------------------------------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: Logistics-------------------------------------------

To help in our planning, please indicate from the choices below one breakout from each session that you would most be interested in attending.

*Breakout Session #1

*Breakout Session #2

Participants are invited to create formal poster displays illustrating aspects of their program or organization, or to share research and assessment findings.  These posters will be on display throughout the event, and there will be dedicated time during the lunch break for guests to speak with representatives from the programs on display.  Please indicate below if you plan to bring a poster display.

**Will you bring a poster presentation?

If Yes, please give presentation title

-------------------------------------------Section III: 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 February 14, 2018. 

Registration is limited to the first 90 registrants!   
    
Registration costs per person:    
$25 Per Faculty/Staff from Campus Compact member institutions  
$40 Per Faculty/Staff from Non-Campus Compact member institutions
$15 Per Community Partner (limited to 3 per organization)
Free for Students  

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 February 14, 2018. 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.

Create Your Own Form
using this Template

Want the ability to collect information with an
online form that looks like this one?