Registration+Form

= 2011 John Muir Academy Registration Form =



**2011 John Muir Academy Application**

**July 18 - 22, 2011 - Verona High School**

Name: Address: Phone: E-mail:

School District: School: Grade Level: Discipline Taught: School Phone: Public or Private:

Please check here if you would like vegetarian meals:

Please list below the code # and workshop title you would like to attend. List two alternatives in the case that your first choice is full or we are not able to run your preferred workshop due to low enrollment.

First Choice: # and Title: Second Choice: # and Title: Third Choice: # and Title:

You may have additional pay/credit options through your district - contact your district for more information.

Check here if you are interested in becoming an ide@s Research Scholar:

Cost: We ask that registrations be in by June 18, 2011. All fees include a non-refundable $50.00 processing fee. Registrations received on or before June 18, 2011: $375.00 Registrations received between June 19 and July 17, 2011: $400.00 Registrations received on July 18, 2011: $425.00

No refunds will be given to cancellations the week before the Academy or for "no shows". Fees include workshop, business tour, continental breakfast, breaks, and lunch.

We will gladly accept registration fees through a payment plan option, as follows: In order to qualify for the payment plan option, we must receive your registration by June 18, 2011
 * Send in your registration with first payment of $100.00
 * An invoice will be sent for a second payment of $100.00
 * A last invoice will be sent for the last payment of $175.00
 * All payments must be received by July 18, 2011

Please check here if you would like to participate in the payment plan option:

Please make registration checks payable to John Muir Academy.

Graduate Credit Oppurtunities: Viterbo University Credit Options: 1 credit: $130.00 2 credits: $235.00 3 credits: $325.00 Please check here to receive application materials for Viterbo University: Number of Credits:

Complete this form and send to: John Muir Academy PO Box 259412 Madison, WI 53725-9412

You may also e-mail this page to us and we will send you an invoice. heidiminster@yahoo.com m_balch@yahoo.com

A confirmation packet will be sent out 2 weeks prior to the start of the Academy.

**To be completed by John Muir Academy**
Mailed E-mailed Payment Method: __Check Enclosed__ Date Received Amount Received Check # PO # __Date Billed__ Date Invoice Received Amount Received Check # PO # __Payment Plan__ Date Received 1st Payment Amt/ Date/ Chk # 2nd Payment Amt/ Date/ Chk # 3rd Payment Amt/ Date/ Chk#