Please read directions below

MASCD Event Name: Date of Event:
Participant's Name: Participant's Title/Role:
School District: School Name:
Address:
City:   State:   Zip:
Work Phone:   Fax: Home Phone:
**E-mail:
**E-mail address is required for confirmation of registration

Total Amount (Registration + Books)

Payment Information:
        Check (made payable to MASCD)  Please bill Purchase Order Number:
        Visa     MasterCard
        Account Number: Exp. Date:   
Special Needs or Comments? Please list here:

Directions:

Please complete this form, print it out on your computer, and mail with payment, or approved purchase order to MASCD. Registrants using purchase orders or credit card may fax form (see fax number above). One registration form per participant; please duplicate this form as necessary. Registration confirmation will be by e-mail. MASCD reserves the right to cancel or reschedule programs when necessary. Please read our Cancellation and Refund Policies.