PARTICIPANT INFORMATION FORM

Margaret Sue Copenhaver Institute, June 23-25, 2014

PLEASE RETURN BY APRIL 14.

(If you must decline the invitation, please inform us as soon as possible).

Your Name: rRev. rDr. rMr. rMs. rMrs.

Title/Position (Include grade level)

Home Address

Street Address City, State, Zip

School Info

School Name School District (e.g., Brown County Schools)

School Address

School Phone Home Phone

E-mail Address

● Are you either an active or inactive member of KDP International Education Honor Society? rYes rNo

● Are you a Roanoke College student or alum? rYes rNo

● Have you supervised a Roanoke College preservice teacher in the last three years? rYes rNo

Please check as applicable:

r I accept my position as participant in the Copenhaver Institute.

r I cannot accept my position as participant in the Copenhaver Institute.

Lodging:

Campus lodging is optional. If you choose to stay on campus, a complimentary room in a residence dormitory hall will be provided for Monday evening, June 23, and Tuesday evening, June 24. NOTE:

With exceptions for married couples, all rooms are single. Rooms are air-conditioned, clean and offer basic furnishings. Residents on each floor share a bathroom and shower facility. If desired, you may elect, instead, to make reservations at an area inn. All off-campus arrangements must be made by the participant. Please see the MSCI Web site (www.roanoke.edu/msci/) and click on the “This Year’s Program” tab, “Lodging,” to view a list of off-campus facilities. If campus lodging is requested, please note that a $20 room key deposit (in form of cash or check) is required upon check-in and will be returned at checkout.

r I do not choose to stay on campus.

r I choose to stay on campus. I need accommodations for:

r Single room–Female r Single room–Male

r Married Couple (please indicate spouse name)

Early Arrivals:

Those traveling significant distances to attend the Institute may request lodging on the Roanoke College campus for Sunday evening, June 22. There is a $40 charge for this. If you would like to request this option, please designate below and also include an additional $40 with your registration fee.

r I would like to reserve a room for Sunday evening, June 22.

Fitness Opportunities:

r Please sign me up for a Tuesday afternoon walk through Salem’s scenic Greenway River Walkway.

r Please sign me up for an early morning fitness walk on Tuesday.

r Please sign me up for an early morning fitness walk on Wednesday.

Special Needs:

We want to make sure that while you are at the Copenhaver Institute, you have your physical needs met. Please indicate below any special needs that you have:

r I would prefer to order a vegetarian meal for the Institute luncheon on June 25.

r I will need lodging that is wheelchair-accessible.

If there are other requests you would like to make, please indicate:

Directory:

Do we have your permission to include your name, e-mail address, school and division in a directory that will be provided to fellow participants? The directory will not be provided to any organization or individual other than MSCI participants. It serves as a means for participants to keep in touch with one another following the Institute.

r Yes, I would like to be included in the participant directory.

r No, I would prefer not to be included in the participant directory.

Workshop Designation:

In order to provide relevant workshops, we hope to offer breakout sessions designated by grade level taught. Please designate your preference for these sessions.

r PRIMARY GRADES (K-2) educator

r UPPER ELEMENTARY GRADES (3-5) educator

r MIDDLE SCHOOL (6-8) educator

r HIGH SCHOOL (9-12) educator

r ADMINISTRATOR (Title: )