Western Illinois University: Macomb Campus
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Dealing with Difference Institute
Registration Form for Participants Not Affiliated with WIU
City/State/Zip Code: _____________________________________________________________
Day Phone (include area code): ___________________ Email: __________________________
_____ $15 Registration received by May 7, 2013
_____ $25 Registration received after May 7, 2013
_____ $ 5 Student Registration received by May 7, 2013
_____ $10 Student Registration received after May 7, 2013
_____ $30.00 All Meals & Refreshment Breaks
_____ $15.00 Dinner - Tuesday, May 14
_____ $15.00 Light Continental Breakfast Buffet & Lunch - Wednesday, May 15
_____ I prefer vegetarian meals.
*We encourage you to have your meals with Institute participants; doing so provides a valuable opportunity to exchange ideas and to carry on the discussions initiated during the sessions.
If you need special accommodations, please contact Janice Welsch (firstname.lastname@example.org / 309-298-2057).
Total Amount Enclosed (Fees + Meals) $ __________
Return the completed registration form with a check for the appropriate amount payable to WIU-DWDI.
Western Illinois University
1 University Circle
Macomb, IL 61455-1390