Pennsylvania Intramural-Recreational Sports Association
Conference Registration Form
September 28-29, 2006
KUTZTOWN UNIVERSITY
Fax the completed form to: (610) 683-1379, Attn: PIRSA Conference Committee
Or mail it to: PIRSA Workshop 2006
DEADLINE For Registration: Registration is due by September 15, 2006
Late Registration is due by September 22 (add 10.00 late registration charge to cost)
Name: _______________________________
Name as you would like it appear on your name tag: ___________________
E-Mail: ____________________________________
Organization: ______________________________________________
Address: ____________________________ City: _____________________State/Province: _______Zip: _________
Home Phone: ( )___________ Work Phone: (______
Registration confirmation will be sent via e-mail only.
Registration Rates (check only those that apply)
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Professional Rates |
Student rates |
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q Conference Registration (includes 2005-2006 PIRSA Membership) and all conference fees, including dinner on Thursday Night |
q Conference Registration ONLY (includes 2005-2006 PIRSA Student Membership) |
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q Late Registration Fee (If Applicable) |
q Conference Registration (includes Keynote Speaker dinner on Thursday Night) |
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q Check Here if You have Submitted a Presentation or Poster Proposal (both student and professional) |
q Check here if you desire free housing option in Gym B for Thursday Night |
