Online Registration Form

Registration
Information:
Curriculum Institute Registration Form
April 25, 2015
Print first 3 letters
of last name here
Each participant must complete an individual registration form
PRINT FIRST NAME
LAST NAME

Home or cell Phone number

Address
City
State
Work Affiliate
Zip
Wk Phone

Work Address
City
If MO work address then MOPD ID# is REQUIRED
Email Address —PRINT CLEARLY
Each participant must fill out
their own individual registration
form.
State
Zip
To use the online form, please
enter all information as required,
and check the appropriate box for
member or non-member rate. If
ordering raffle tickets, please enter
the dollar amount in that box.
Totals will be generated
automatically
You may print this form and
send with payment, or see below
for instructions for processing
with a credit card through PayPal.
Please select lunch sandwich choice
_______ Veggie
________ Turkey
_______ Ham
________ Roast Beef
Confirmation and other info will be sent
NAEYC Member
Membership Number: ______________
Expiration Date: __________________
REGISTRATION
Non-Member
Membership is in an individuals name.
Directors cannot use their membership number
for their staff.
REGISTRATION
Instructions for
paying by
Credit Card
(approved through
Pay Pal)
 Fill in the form and using the
mailed by Apr 11: $60.00
________
mailed by Apr 11: $75.00
________
Raffles Tickets:
One for $1.00 or 6/$5.00
________
Raffles Tickets:
One for $1.00 or 6/$5.00
________

Onsite April 25
Add $10.00 late fee
________
Onsite April 25:
Add $10.00 late fee
________

$ 0.00
Total Amount enclosed ________

$ 0.00
Total Amount enclosed ________
Method of Payment
Check Check Number_________________
PO
Cash
PO Number____________________
____________________________
Credit Card– through Pay Pal
Return this registration form
with payment by Apr 11, 2015
to:
Mid-America AEYC
c/o Cindy Imhauser
PO Box 2136
Lee’s Summit, MO 64063

—OR—
PROCESS
with a
CREDIT CARD
by
For Office Use:
Postmark date________________ Member
“save” button” at the bottom of
the form, “Save” the form to
your computer as “your name
CCReg” (i.e. John Doe CCReg )
Y N
Personal Number_____________ Group # _________
Tickets______________________________________
SAVE
April 18, 2015
PRINT

Attach the saved form to an
email and send to:
[email protected]
An email with an invoice will be
returned to you within 24 hours.
You will then process your payment through PayPal following the
directions generated in that email.
Once processed you will receive a
receipt from PayPal and your
registration will be com-pleted.
Centers paying for multiple
participants, should attach all
individual registration forms to
one email, then one invoice can
be created with one total
amount due.
PayPal is only the “clearing
house” for approving the credit
cards and accepts Visa,
MasterCard, American Express,
Discover, eCheck, and PayPal
balance payments