Cultural Detective Registration Form
October 31-November 1, 2010
Minneapolis, Minnesota
Name:
Gender:
Male
Female
First name / nickname
for nametag:
Title:
Organization:
Street
:
City:
State/Province:
Zip/Postal Code:
Country:
This address is
Home
Work
Both
Home phone:
Cell phone:
Work phone:
Fax number:
Email
:
In case of emergency, we should contact:
Name:
Relationship:
Address:
Home/Cell phone:
Work phone:
CULTURAL DETECTIVE® FACILITATOR WORKSHOP TUITION
$700
if paid in full 21 days prior to workshop
$750
$300
Optional Credit available through Portland State University (register through ICI)
METHOD OF PAYMENT
U.S. bank check or money order
Date mailed:
Purchase order
PO #
PayPal
Credit card payment can be made through PayPal or by contacting ICI directly via phone or fax.
