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Registration Form for Participants Not Affiliated with WIU

20th Annual Dealing with Difference Institute
Tuesday & Wednesday, May 14 - 15, 2013
Multicultural Center
West Murray Street (Dr. C. T. Vivian Way) 
Western Illinois University, Macomb
   

Name: _______________________________________________________________________

 

Title/Department: _______________________________________________________________

 

Institution: ____________________________________________________________________

 

Address: ______________________________________________________________________

 

City/State/Zip Code: _____________________________________________________________

 

Day Phone (include area code): ___________________ Email: __________________________

 

Institute Fees

_____ $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

 

Meals*

_____ $30.00 All Meals & Refreshment Breaks

OR

_____ $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 (jr-welsch@wiu.edu / 309-298-2057).

Total Amount Enclosed (Fees + Meals) $ __________

Return the completed registration form with a check for the appropriate amount payable to WIU-DWDI.

Mail to:

IACD/Simpkins 207

Western Illinois University

1 University Circle

Macomb, IL 61455-1390