Fillable Registration Form (University of Dayton)

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Registration Form (University of Dayton)

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2019 Catholic Education Summit Registration Form
Friday, June 21, 2019 | University of Dayton Kennedy Union
Please mail this completed form to the address below:
U.D. Center for Catholic Education
ATTN: Barb Miller
300 College Park Ave., Fitz Hall 652
Dayton, OH 45469-2967
Make checks payable to U.D. Center for Catholic Education
Select one: _____ Single participant: $25 _____ Team of participants (4-6 people): $100
Participant name(s): __________________________ _______________________ Email: ______________________
Last (yours) First
__________________________ _______________________ Email: ______________________
Last (team member #2) First
__________________________ _______________________ Email: ______________________
Last (team member #3) First
__________________________ _______________________ Email: ______________________
Last (team member #4) First
__________________________ _______________________ Email: ______________________
Last (team member #5) First
__________________________ _______________________ Email: ______________________
Last (team member #6) First
School/Org. name: ________________________________________ School/Org. Arch/Diocese: _________________________
School/Org. info: _________________________________________ _______ ________________
City State Zip
Contact number (incl. area code): _________________________ Type: _____ Cell _____ Home _____ Work
Role in your organization: _____________________________________________________________________________________
If you (or anyone on your team) is a teacher, which grade(s) are you/team members teaching?
Do you (or anyone on your team) have any dietary restrictions? ___ No ___ Yes
If yes, please describe:
Do you (or anyone on your team) require accommodations for purposes of mobility/hearing/vision/other? ___ No ___ Yes
If yes, please describe:
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Registration Form (University of Dayton)

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Completed 22 July 2020

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