2010 SIIC Registration Form
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:
  
:
  
     
In case of emergency, we should contact:
     
Name:
  
Relationship:
  
Address:
  
Home/Cell phone:
  
Work phone:
  
     
HOUSING    
Participants stay in modern residence halls with same-sex shared bathrooms. A semi-private double has two beds in one large room
divided by a partition wall.
Semi-private Double without A/C  
Single without A/C  
Off-campus (Participant to arrange own housing.)  
     
Extra night(s) requested:


Saturday, July 24
      With meals Without meals
         
SESSION I: July 14-16 (3-day workshop)
1st choice:
2nd choice:
Semi-private Double, without A/C:
Single, without A/C:
Off-Campus
  $1490
$1520
$1040
 
A SAMPLE OF SIIC: July 17 (1-day workshop)
1st choice:
2nd choice:
Semi-private Double, without A/C:
Single, without A/C:
Off-Campus
  $525
$540
$370
 
SESSION II: July 19-23 (5-day workshop)
1st choice:
2nd choice:
Semi-private Double, without A/C:
Single, without A/C:
Off-Campus
  $2300
$2330
$1690
 
SESSION III a: July 26-30 (5-day workshop)
 
1st choice:
2nd choice:
Semi-private Double, without A/C:
Single, without A/C:
Off-Campus
  $2300
$2330
$1690
 
SESSION III b: July 26-28 (3-day workshop)
1st choice:
2nd choice:
Semi-private Double, without A/C:
Single, without A/C:
Off-Campus
  $1490
$1520
$1040
 
Years previously attended SIIC or Cohort #
 
AMOUNT OF CURRENT PAYMENT
 
METHOD OF PAYMENT
Date mailed:
  PO #
Credit card payment can be made through PayPal or by contacting ICI directly via phone or fax.