Academy for Academic Leadership

Registration Form
Institute for Allied Health Educators
Building on the Basics

Live in-class sessions: October 7-9, 2011
Online follow-up session on October 19, 2011

REGISTRATION DEADLINE: September 26, 2011

The registration fee for theADEA/AAL IAHE is $695.

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:
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 the ADEA/AAL IAHE?:
(*) - please specify:
The registration fee for the ADEA/AAL IAHE is $695.
Invoice Information:	To be invoiced for the registration fee, 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 the ADEA/AAL IAHE, 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 $695 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 26, 2011, 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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