Registration Form
December 2-6, 2009
Westin South Coast Plaza – Costa Mesa, CA
Participant
Position Title
Faculty
Administration
Name of Institution
Address
City/State/Zip
Phone
Email
I would like to have vegetarian meals
Name of Assistant
(If applicable)
Phone
Email
Name of President
INSTITUTE TUITION - $950
Special Stimulus Rate
: $800
Check enclosed in the amount of $ College Purchase Order No.
Please make payable to: CCC Foundation – Kaleidoscope (Federal ID#: 33-0094898)
Please send invoice
Last Day to Register: November 30, 2009
Last Day to Reserve Hotel Rooms at the Kaleidoscope Rate of $179: November 8, 2009
Reservation request received at the hotel after 5 p.m. PST on the cut-off date will be accepted on a space and rate availability. Make
your reservations directly with the Westin South Coast Plaza by calling (888) 627-7213. To make your room reservation online, visit
http://www.starwoodmeeting.com/Book/kaleidoscopeonine.
Be sure to identify yourself as a Kaleidoscope 2009 member.
Please fax this form to
(714) 241-6155
, or mail to: Robyn Chapman, Foundation Office – Kaleidoscope
Coastline Community College, 11460 Warner Avenue, Fountain Valley, CA 92708-2597 http://coastline.edu/kaleidoscope
NOTE: Refund requests must be in writing and received by November 18, 2009.
PLEASE TYPE OR PRINT CLEARLY
Call
(714) 241-6157
for more information.
Staff
Other
Fax
Fax
Note: If you would like to pay by credit card, please call Robyn Chapman at (714) 241-6154.
Text Field
To submit via email, you must first save this
form to your computer, then attach it to an
email addressed to kaleidoscope@coastline.edu
