REGISTRATION FORM
Name _____________________________________________________________________________________
School/Organization Name ____________________________________________________________________
Position/Job Title ____________________________________________________________________________
Address ___________________________________________________________________________________
City ________________________________________________ State ____________ Zip __________________
Phone Number _____________________________E-mail ___________________________________________
Professional Rates
Full Conference Options
Registration Dates
Registration Fee
__Back to School Special
__Full Conference
__Group Rate (4 or more)
Ends August 31, 2016
Ends October 6, 2016
Ends October 6, 2016
$179
$199
$159
Parent and Student Rates
Full Conference Options
Registration Dates
Registration Fee
__Back to School Special
__Full Conference
__Student (with student ID)
Ends August 31, 2016
Ends October 6, 2016
Ends October 6, 2016
$129
$149
$79
Single Day Rates
Single Day Options
Registration Dates
Registration Fee
__Thursday 1-Day
__Friday 1-Day
Ends October 6, 2016
Ends October 7, 2016
$100
$100
Scholarship Information
____ I have submitted an application for a scholarship and am awaiting response for a community grant.
____ I desire a partial scholarship to attend. I am able to pay $__________________________________.
____ I would like to volunteer on ___ Day 1 or ___ Day 2 in exchange for a Single Day Conference ticket.
A limited number of partial scholarships are available. Please reserve partial scholarships for attendees that
would be unable to attend the conference otherwise. Limited volunteer opportunities will also be available.
Completing the form does not ensure that you will be chosen.
Volunteer opportunities will be awarded by need and ‘first come, first serve’ basis.
PAYMENT INFORMATION
Check or Card Information
Check # __________________
Payment Type
Make checks payable to Bridgeway Services, LLC
____ VISA ____ MasterCard ____ AMEX
Total Fee on Card $_______________
Credit Card Holder Name _____________________________________________________________________
Credit Card # ____________________________________________ Expiration Date (MM/YY) ______________
Signature _______________________________________________________ CVV #______________________
Purchase Order Information
Purchase Order # __________________ Organization Name _________________________________________
Billing Address/City/State/Zip __________________________________________________________________
Contact Person ________________________________ Daytime Phone Number _________________________
(If registering by purchase order)
Mail
Fax
(866) 477 – 9816
130 Inverness Plaza #384
Birmingham, AL 35242
www.evolvealabama.com
E-mail
[email protected]
Please submit this entire registration form for your registration, even if you are requesting a partial scholarship.
For multiple registrations, please duplicate this form. For those registering for four or more from the same
organization to obtain a group rate, please complete a registration form for each person and mail the forms
together with the purchase order number or one check for the combined registration fees.
Attendees may transfer pre-paid registration to another attendee at no cost. If this is necessary, please email
Kerry Mataya at [email protected] for a request to transfer a registration. Please include the
current registered name and the attendee that the registration will be transferred to. All EVOLVE registration
cancellations will be charged a $30 processing fee before Friday, September 16, 2016. No refunds will be given
after Friday, September 16, 2016.