Name:

Organization:

Preferred Mailing Address (Street):

City:

State: Zip:

Country:

Phone:

Fax:

Email:

Website:

How did you hear about the conference?

Select a choice Direct Mail Electronic Mail Web Site Word of Mouth Other

Please use the space below to include a brief (50 word) bio and contact info, if appropriate. This information will be used for the conference bio list unless you specify otherwise.

Race/Ethnicity:

(Your response is optional but we are committed to ensuring a diverse group of participants)

Gender (for room assignments): Gender Male Female

Would you be interested in being a Notetaker for one or more of the sessions? We are looking for people who can take clear and comprehensible notes that will later be used in writing the 2003 Conference Report.

  I would like to volunteer as a Notetaker.  (Information/instructions will be provided at registration)

SCHOLARSHIP QUESTIONS:

1. Please describe your current work or interest in community participation:

2. What do you hope to learn or gain from the conference? Please describe your plans for sharing what you learn in your community:

3. Please give an example of an experience in your life that has stimulated your interest in this work and your participation in this conference:

4. Explain your need for a scholarship:

5. Please provide the name and contact information for someone who can speak to your work or interest in community issues:

Registration Fees: 

Applicants for full scholarships do not need to complete the questions directed towards partial scholarships until we have responded to your request.  If you are applying for a partial scholarship, please include a check for the Registration fee and any other expenses not requested in scholarship application.  Fee is required to secure your space.  (Non-refundable after September, 26, 2003). Remaining balance is due by September, 26, 2003.

I am applying for Select One Partial Scholarship Full Scholarship (check one): (please be realistic, there is a set amount in our scholarship fund, and we prefer to provide support to as many people as possible. You will receive notification of monies allocated by Sept.12)

Individuals ……………………………………………… $ 125.00
Low-Income ………………...…………………………… $ 35.00

select fee $125.00 $35.00 (low income/partial scholarship) Full Scholarship

I will be paying by select one On-line credit card check Full Scholarship

Partial Scholarship (Please fill in amounts below. A number must be inserted into the next four boxes in order for the form to be processed. Zero (0) works in those spaces not applicable. It has to be a number though, not a letter or word.)

Travel Expenses* (you must fill out the transportation info below) amount requested:
$
Room and Board (housing and meals) amount requested: $
Child/elder care (at home) amount requested: $

Full Scholarship (travel, housing, meals, child/elder care and registration. Insert a (0) if applying for a partial scholarship.)* 
amount requested: $

*Travel expenses include flight and transportation to/from airport, or mileage. Upon acceptance, we will notify recipients of amount allotted for travel and/or child/elder care. Scholarship recipients are responsible for arranging travel. Recipients will receive reimbursement for travel and/or child/elder care after conference after receipts are submitted. Special arrangements can be discussed if prepayment of travel/care is impossible.

Accommodations and Food: On-site housing is available, but limited. All dorm-style rooms have 8 single (bunk) beds and a private bath. Pricing is for 4 or 8 persons per room.

FOOD: the in-house chef prepares wonderful meals and can accommodate some special diet needs. Packages include accommodations, linens, meals and snacks.

room options 4 person per room/6 meals/2 nights $130 4 person per room/9 meals/3 nights $170 8 person per room/6 meals/2 nights $100 8 person per room/9 meals/3 nights $140

I want to room with:

I would consider an off-site hotel with meal package if the Audubon Center is full, or because I need one night only accommodation with meals. select one Yes No

Insert nights you will be staying at the Center.

I will attend the Thursday night dinner and/or reception from 7-9 PM.

select one Dinner and Reception Dinner Reception Not Attending

Special Needs: Insert special needs regarding dietary, environmental, disability access & needs, etc.

TRANSPORTATION: The Audubon Center is located about two hours north of the Minneapolis/St. Paul (MSP) airport. Van shuttles will be available from the airport at these designated times only on a first come first served basis. YOU MUST reserve a space below. The cost will be $30/person round trip to be paid by Sept. 26. Please plan to arrive at least 45 min. before van pick-up.

Airport Pick-ups: Thursday, Oct. 16 -- 3:00 PM; 4:30 PM and 7:30 PM. Friday, Oct. 17 -- 11 AM – only.

Leaving Conference: (allow 2 hour travel time + check-in) Sunday, Oct. 19 -- 11:00 AM, 12:00 Noon and 1:00 PM.

Get a 10% discount on NorthWest airlines if reserved 30 days in advance (by Sept. 16), 5% thereafter.  Call: 1.800.328.1111 WorldFile NM2ZL, 7am – 7 pm CST, M – F.

Note: if arriving/leaving at other than scheduled shuttle times, you are responsible for your own transportation. Driving directions are on our website. Questions or concerns? Contact Teresa Konechne (contact info below). You will receive a confirmation and shuttle pick-up site once reservation is made and fee paid.

I am arriving by: select one Car Bus Airplane Train to the select one Audubon Center MSP airport Other

  I will need van shuttle transportation ($30/person round trip paid in advance or included in scholarship) to and from the Minneapolis airport to the Audubon Center.

Arrival time and date:

Departure time and date.

Car pooling: I will have a car at the airport and could assist people with transportation needs from/to the airport

Arrival time and date:

Departure time and date.

Additional Information: