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Invited Guest Conference Registration
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Name
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Prefix
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Dr.
Ms.
Mr.
Mrs.
Mx.
Name
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First
Last
Name on Badge
School/Organization
*
Role
*
Faculty – Higher Education
Early Career Faculty (1st – 3rd year)
Administration – Higher Education
Administration – Public/Private School
Teacher – Public/Private School
State Education Agency
Student
Education Association
Other
Role - Other
*
Professional Area of Focus
Assessment Director/Coordinator
Director of Field Experiences
Graduate Student
Higher Education – Educational Leadership
Higher Education – Teacher Leadership
Higher Education – Teacher Education
School Counseling
PK-12 Teacher – Grade Level/Content Area
PK-12 Other School Base Employees
Undergraduate Student
Other
Professional Area of Focus - Other
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Address
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Email
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List any Dietary Restrictions (enter “N/A” if none)
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Will you be in attendance for lunch?
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Yes, I will be attending.
No, I will not be attending.
Will you be in attendance for the social gathering?
*
Yes, I will be attending.
No, I will not be attending.
Will you be in attendance for lunch?
*
Yes, I will be attending.
No, I will not be attending.
Will you be in attendance for the mentor teacher dinner?
*
Yes, I will be attending.
No, I will not be attending.
Will you be in attendance for the concluding lunch?
*
Yes, I will be attending.
No, I will not be attending.