Graduate Music Education
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ACDA Registration

2012 ACDA CONFERENCE REGISTRATION FORM

PAYMENT OF REGISTRATION FEES
You will receive a confirmation email within 48 hours of submitting your registration online.

Please mail payment for your registration fee with a copy of your email confirmation within 7 days. Registration is not considered complete until payment has been received.

Checks and money orders accepted, made payable to Gordon College.

Mail payment to:
Gordon College Graduate Music Office
255 Grapevine Road
Wenham, MA
01984

CANCELLATION AND REFUND POLICY
Registration must be cancelled prior to or on July 1 in order to receive a full refund. No refunds will be offered after July 1. Cancellation must be received in writing and is offical only when an email has been received at kristen.harrington@gordon.edu, or fax at 978.867.4655. Non-attendance does not constitute a cancellation.

1. First Name

2. Last Name

3. Birth/Maiden Name

4. Gender

Male
Female

5. Date of Birth

6. Mailing Address Street

7. City, State, Zip

8. email address (primary)

9. email address (alternate)

10. Home phone

11. Cell Phone

12. Emergency Contact (Name, relationship, contact number)

13. Citizenship

United States
Other

14. Ethnicity

15. Current School District

16. Are you requesting graduate credit for your participation in the conference?

Yes
No

17. Are you requesting Professional Development Points for your participation in the conference?

Yes
No

18. Have you previously registered for graduate courses, workshops or conferences at Gordon College?

True
False

19. If you are a current member of ACDA, please list membership # here (non-members will be charged an additional $35)

20. Please choose type of registration here:

$230 : Conference Registrations received by May 15 (eligible for a maximum of 45 PDPs; requires attendance documentation for contact hours and summary paper)
$250 : Conference Registration received after May 15 (eligible for a maximum of 45 PDPs; requires attendance documentation for contact hours and summary paper)
$600 : Conference Registration > eligible for two (2) graduate credits (requires attendance documentation for 24 contact hours and summary paper)

21. CERTIFICATION REQUIREMENT
My signature indicates all information in this form is correct and complete. I understand and agree to the cancellation and refund policy as stated and that misrepresentation or omission of information is grounds for cancelling my registration. I agree to comply with the behavioral standards of Gordon College while on campus or any other graduate class site, and respect the underlying principles and assumptions upon which they are based.

Yes
No