Conference Printable Registration Form

April 3­5, 2016
Hot Springs, Arkansas Convention Center
Planning and Preparation:
Putting the Pieces Together
ARKANSAS ASSOCIATION OF MIDDLE LEVEL EDUCATION
Embassy Suites Hotel and Convention Center Hot Springs, AR April 3­5, 2016
REGISTRATION FORM
LAST NAME ____________________________ FIRST NAME ______________________________ MI____
SCHOOL OR ORGANIZATION _________________________________ DISTRICT _________________________
POSITION _______________________________________________________________________________________
ADDRESS ____________________________________ CITY ________________ STATE ______ ZIP ____________
PHONE (______) ________________________ E­MAIL ADDRESS ________________________________________
COOP/REGION ____________________________________________________________________________________
Section A: √
Section B: MEMBERSHIP AND SUBMITTING REGISTRATION Not a member? Join today and save! Complete a membership application form and register as an AAMLE member
REGISTRATION FEES
Please circle the appropriate selection
Already a member
Pre­Service
Emeritus / Retired
Individual Member
Basic Institutional
$25
Membership application completed
$200 Comprehensive Institutional*
$50
$225
Registration Before March 14
$225
Registration Before March 14
Comprehensive Institutional
$100 Institutional*
$265
$50 Individual
$10 Pre­Service**
$265
$225
Non­Member
$325
Students may register at anytime during the registration period for the above rate.
Total Registration Fees: $___________________
*Institutional Memberships
Comprehensive‐Building Administrators & Certified Staff
Basic‐Includes One Administrator & Four Certified Staff
**Pre‐Service for up to four years
Total for Section B Membership $________________
TOTAL AMOUNT DUE (A+B) $________________
FORM ON BACK COMPLETED ____________
PAYMENT METHOD:
___Check here if paying by credit card. Someone from the AAMLE will call you for more information
___Check here if paying by check. Make check payable to “Arkansas Association of Middle Level Education”
*Note – a valid hard copy of purchase order must accompany the form in order to be processed
ARKANSAS ASSOCIATION OF MIDDLE LEVEL EDUCATION
Membership Form NAME
POSITION
SCHOOL
DISTRICT
REGION/Co­op
MAILING ADDRESS
CITY
STATE
ZIP
HOME PHONE
WORK PHONE
E­MAIL ADDRESS
WORK/ALTERNATE E­MAIL MEMBERSHIP OPTIONS:
Indicate option below:
INSTITUTIONAL BASIC MEMBERS:
List the names of four additional staff members at your
school to receive benefits:
_____ Institutional Comprehensive ($200 per year)
1. Name ____________________________________
Includes building administrators and certified staff E­Mail ___________________________________
_____ Institutional Basic ($100 per year)
2. Name ____________________________________
E­Mail ___________________________________
Includes one administrator and four certified staff
_____ Individual ($50 per year)
3. Name ____________________________________
E­Mail ___________________________________
_____ Pre­service ($10 up to 4 years)
4. Name ____________________________________
E­Mail ___________________________________
Institutional Comprehensive – Send attached list of building certified staff PAYMENT METHOD:
with email addresses.
Indicate Payment Method Below:
Check
Check Number __________________________________
Purchase Order (attached)
PO Number ____________________________________
Credit Card *If paying by credit card, someone from the LRCVB will call you for more information. Mail the completed form to:
AAMLE
ATTN: Membership Chair
PO Box 1385, Fayetteville, AR, 72702
If you have question, contact David Skelton at the above address or call 479­409­8680
EDUCATION CO­OPS BY REGION
CENTRAL
Arch Ford
Pulaski Co. Schools
NORTHWEST
Northwest
Ozarks
Western
Unlimited Resources
(O.U.R.)
NORTHEAST
North Central
Northeast
Crowley’s Ridge
Wilbur Mills
SOUTHWEST
DeQueen­Mena
Southwest
Dawson
South Central
SOUTHEAST
Great Rivers
Southeast
Arkansas River