Academy for Academic Leadership

Registration Form
2010 Center for Advancing Learning and Teaching

PROGRAM DATES • September 16-18, 2010

REGISTRATION DEADLINE: September 3, 2010

Bolded fields are required
Full Name:
Preferred First or Nickname:
School or Institution Affiliation (if any):
Title/Academic Rank (if any):
Mailing Address:
City:
State (if USA):
Country (if other than USA):
Zip Code:
Email Address:
Work Phone:
Home or Cell Phone:
Fax Number:
Highest degree(s)/certification(s) attained:
If you currently hold an academic position, please indicate if your appointment is:
Please indicate if you are willing to have your name and contact information listed in the directory of participants:
How did you learn about CalTEACH?:
(*) - please specify:
The registration fee for CalTEACH is $2,750 Invoice Information:	To be invoiced for the $2,750 tuition, please provide the contact and address information here. Otherwise, please put "Credit Card" and you will be able to pay by credit card after submitting this form.
I understand that if I am selected to participate in CalTEACH, I am required to attend all activities and complete all assignments throughout the program. I understand that, once I am accepted, the tuition fee of $2,750 is due within 30 days of receiving acceptance into the program. Failure to submit the tuition by the deadline will result in the loss of my position in the program. After September 3, 2010, withdrawal from the program for any reason will result in the forfeiture of 50% of the tuition. I also understand that the conduct of this program is contingent upon adequate enrollment and factors beyond the control of the Academy for Academic Leadership. Should the program be cancelled for any reason, I will receive a full refund of any tuition paid to the Academy for Academic Leadership. The Academy for Academic Leadership is not responsible for other costs that I incur as a participant in the program. I understand that the Academy for Academic Leadership is not a placement agency and makes no promise of employment as a result of participation in the program. My typed or signed name and submission of this form constitutes my Agreement to Participate.
I Agree:
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Terms and Conditions	I Agree

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