Communities Cultivating Character Conference Registration Form
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Mail To:
Registration Services
The University of Alabama
Box 870388
Tuscaloosa, AL 35487
CS-2309-CCCC01-01
Please submit this entire page for your registration. For multiple registrations, please duplicate this form.
[ ]Mr. [ ]Ms. [ ]Dr. First:____________________________Middle Initial:________Last:____________________________
Preferred Name/Nickname:____________________________
Company/Organization Name:____________________________
Mailing Address:____________________________City:____________________________State:________Zip:______________
Email Address:____________________________Phone:____________________________
Job Title:____________________________
[ ] Enclosed is a check for $____________________________ made payable to THE UNIVERSITY
OF ALABAMA
[ ] Purchase order is attached.
[ ] Charge $____________________________to credit card: [ ] MasterCard [ ] VISA [ ] American Express [ ] Discover
Card #____________________________Exp. Date (M/Y)____________________________
Security / Verification / CVV Code____________________________(Three or four digit code on back or front of credit card.)
Authorizing Signature:____________________________
Registration Fee:
[ ] $125 – Full Conference Registration
[ ] $75 – One Day Attendance select date: [ ] 9/26 only [ ] 9/27 only
[ ] $50 – Teacher Rate (non-leadership role)
Note: The University of Alabama is committed to complying with the Americans with Disabilities Act. Requests for accommodation of physical and/or dietary needs should be made at least 30 calendar days in advance of the program date. Please email your request to ehtownsend@ua.edu. A portion of the invoice amount for this program will go to the Capstone Lifelong Learning Foundation to support activities of The University of Alabama and the Office of Teaching Innovation and Digital Education. Need our STAARS Vendor Number? Please use VC000118827 for UA Office of Teaching Innovation and Digital Education.
Questions? Contact Amanda Bergeron at abergeron@ua.edu