OSTA Conferences - Registration Form

2012 Conference Registration Form

Literacy and Science Across the State

October 12th 2012

Leslie Middle School, Salem, Oregon

Note: If you would prefer to register online,
OSTA now offers an online Conference Registration form (click here).

Name ________________________________________________________________

(Last) (First) (Middle Initial)

Address ___________________________________________________________

(Street Address)

____________________________________________________________

(City) (State) (Zip Code)

Home Phone (____)_______________ Work Phone (____)________________

Email (required) ___________________________ Fax (____)________________

School or Agency ______________________________________________________

Position: Elementary Middle School Secondary Post-Secondary Other

Mark the appropriate boxes and make check payable to OSTA.

In order to qualify for Advance Registration price, your Registration Form must be postmarked by September 28, 2012. After that date, please pay the onsite price. Payment must accompany the registration form to be processed.

Conference Registration - Select one

$80 OSTA Conference Advance Registration and Membership. Includes one-year membership, one-year TOST subscription, conference registration, lunch included. (postmark by 9/28/12)

$95 OSTA Conference On-Site Registration and Membership. Includes one-year membership, one-year TOST subscription, conference registration – a limited number of lunches will be available but not guaranteed. (postmark after 9/28/12 or at door)

$40 Student and Retired Teacher OSTA Conference Advance Registration and Membership. Includes one-year membership, one-year TOST subscription, conference registration, lunch included. (postmark by 9/28/12)

$50 Student and Retired Teacher OSTA Conference On-Site Registration and Membership. Includes one-year membership, one-year TOST subscription, conference registration – a limited number of lunches will be available but not guaranteed. (postmark after 9/28/12 or at door)

Payment Worksheet

Conference Registration	_________
President's Dinner ($25)	_________
Discount price of $55/participant for: Presenters or groups of 5 or more. All group members must submit their forms together.	_________
Total (check or PO included)	_________

Do you have any special needs or dietary restrictions that we can address to make your participation more enjoyable? Please describe on an extra sheet and attach, including evening phone number if applicable.

Refund/Cancellation Policy: Written refund requests must be postmarked 10 days before the conference. Refund/Cancellation does not include the $40 OSTA membership portion of the fee.

Mail to: Paul Zastrow, Membership, 5690 Collins Road, Hood River, OR 97031

Membership: Paul Zastrow, pzastrow@gorge.net

Please print the form, complete the information and send it to address above.

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