First Name Middle Initial Last Name NAEYC Member ID Number

CONFERENCE REGISTRATION FORM

(1 per person, please.)

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First Name Middle Initial Last Name NAEYC member ID Number

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Mailing Address City State Zip Code

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Organization Telephone Number Fax Email

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Student ID # (if applicable) College Emergency Contact and Phone

Position(Check all that apply) : ¨ Teacher ¨ State Agency ¨ Center Administrator ¨ Teacher Educator ¨ Student

¨ Consultant ¨ Public School Administrator ¨ Family Child Care ¨ Head start ¨ Parent ¨ Other:______

Program Involvement(Check all that apply) : ¨ Infant/Toddler ¨ Early Head Start ¨ Head Start ¨ Public Pre-K

¨ For Profit Child Care ¨ Non-Profit Child Care ¨ Grade 1-3 ¨ After School ¨ College Student ¨ Adult Educator

¨ Higher Education ¨ Other:______

MEMBERSHIP IN TAEYC/NAEYC ALLOWS FOR DISCOUNTED RATES!!! Become a member of NAEYC by going to www.naeyc.org/membership and choose Texas and your local affiliate! Or pay for membership with Registration!

CONFERENCE FEES TAEYC MEMBER NON-MEMBER STUDENT

REGISTRATION

3 days ¨ $205 ¨ $325 ¨ $110

1 day(Check one: : ¨ Thursday ¨ Friday OR ¨ Sat) ¨ $80 ¨ $140 ¨ $70

Non-member Registrations (both 1 and 3 day) of 10 or more persons can take a 10% discount of Conference fees!

PRE-CONFERENCE SESSION FEES SPECIAL EVENTS FEES

¨ Train the Trainer $50 ¨ Accreditation Tour - Friday - $30

¨ Public Policy Luncheon - Friday - $45 ¨ Donate $2 to the President’s Trust Fund/T.E.A.C.H. ¨ K-3 Writer’s Workshop – Thursday - $30

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PAYMENT METHOD

¨ Check/Money Order Enclosed (Payable to Texas AEYC) ¨VISA ¨ Mastercard ¨ Discover

Special Needs:  Diabetic  Vegetarian  Wheelchair Accessible  Other______

Printed Name on Card:______Card #______Exp date:______

Billing Address on Card ______City ______State ______Zip ______

Signature of Cardholder______

(For your protection, this information will be blacked out once we run your credit card)