1. Send form by FAX (518-456-9287), mail or e-mail to: NERIC, 1031 Watervliet-Shaker Rd, Albany, NY 12205

Attn: Beth Cash (bcash@gw.neric.org)

2. Forms must arrive at least 5 business days before the start date of the course!!!

3. Use one form per individual. Please include COMPLETE home information.

4. Assume you are registered for a course unless otherwise notified. No affirmative confirmations will be given, therefore,

you should keep a copy for yourself.

5. IF YOU CANNOT ATTEND A CLASS, PLEASE CALL TO CANCEL – THERE MAY BE SOMEONE ON THE WAITING LIST!!!!!!!!

Name: ________________________________ District: _________________________________ Building: ____________________________

Work Phone: _______________________ Fax: _______________________

Email Address: __________________________________________________

Home Address: ___________________________________________ Home Phone: ____________________________

Home City, State, Zip: __________________________________________

Name of Session Location Fee Date(s)/Time of Session

(if NOT a Model Schools District)

_________________________ ___________________ ______________ _______________________

_________________________ ___________________ ______________ _______________________

_________________________ ___________________ ______________ _______________________

6. Payment Options: (if NOT a Model Schools District)

 

q Check enclosed if not a NERIC Model Schools District (district check preferred)

q I authorize NERIC to bill the School District named above for this training workshop because our district does not participate in the

Model Schools Service FOR BOCES USE ONLY

1. Confirmed ________

Signed ___________________________________ Title _____________________ 2. Bill # ________

4. Amount ________