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Register for the WPCID Conference 2011

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Register for the WPCID Conference 2011
April 8-9, 2011

Registration Due By (Deadline Extended): March 4, 2011 March 28, 2011
Step 1: Complete the WPCID Conference registration form below.
Step 2: After submitting the form, mail payment by check for the appropriate amount to:

Beloit College
Office of Intercultural Affairs
Att: Daksha Howard
700 College St
Beloit, WI 53511
Phone: 608-363-2125
Fax: 608-363-7145
Email: howardd@beloit.edu

Participant 1 (full name):*
Demographic Information (optional):
Gender:
Race/ethnic heritage (check all that apply):
Special arrangements (optional):
Are there any ways we can be of assistance in accommodating your physical challenges?
Please list below any dietary requirements you may have.:
Participant 2 (full name):*
Demographic Information (optional):
Gender:
Race/ethnic heritage (check all that apply):
Special Arrangements (optional):
Are there any ways we can be of assistance in accommodating your physical challenges?
Please list below any dietary requirements you may have.:
Participant 3 (full name):*
Demographic Information (optional):
Gender:
Race/ethnic heritage (check all that apply):
Special Arrangements (optional)
Are there any ways we can be of assistance in accommodating your physical challenges?
Please list below any dietary requirements you may have.:
Participant 4 (full name):*
Demographic Information (optional):
Gender:
Race/ethnic heritage (check all that apply):
Special Arrangements (optional)
Are there any ways we can be of assistance in accommodating your physical challenges?
Please list below any dietary requirements you may have.:
Contact Information:
College/University/Office:*
Student Organization (optional):
Mailing Address:*
City:*
State:*
Zipcode:*
Telephone:*
Fax Number:*
Email Address:*
May we publish your name and email address in the conference directory?*
Registration Options:
$200 conference participation fee (covers registration for up to 4 people)
$50 for each additional person
$30 meal fee (For Beloit College faculty and staff only): includes Friday dinner and Saturday lunch
Grand Total:
Emergency Contact Information:
Emergency contact name:*
Emergency phone number:*
Please Complete: