IMLA Registration Payment

"*" indicates required fields

Personal Information

This is information about yourself. We will use this information in the event we need to contact you about this registration. All event information will be emailed to each of Participants entered in the Participant Information section below.

Name*

First Last

Email*

Please provide an email address where event links, updates, and information will be sent.

Who do you work for?*

What school or organization do you work for?*

Participants

Please add each participant you would like to register and pay for, including yourself if you will be attending.

Enter Participants

Name	Email	Grade Level(s)	Title / Role	Please describe your "other" title / role.	Does this participant need any special accommodations to participate in this event?	Please describe any accommodations needed.	Actions

There are no Participants.

Coupon Code

Do you have a code for this event?*

Yes

Enter code here*

Payment Information

How will you be paying?*

NOTICE: There will be a 4% processing fee for all Credit Card transactions. This fee is NON-REFUNDABLE in the event of a cancellation.

Non-Member Registration

Price: $75.00

Credit Card Processing Fee

Price: $75.00

ESC Member Registration

Price: $75.00

Credit Card Processing Fee

Price: $75.00

CIESC Member Registration

Price: $75.00

Credit Card Processing Fee

Price: $75.00

Total

Billing Credit Card

Card Details

Cardholder Name

Billing Address*

Street Address Address Line 2 City State ZIP Code

Price: You will be invoiced by CIESC based on the following tiered pricing. Pair: $1450, Triad: $1950, Quad: $2500, Extra Person: $600

Price: You will be invoiced by CIESC based on the following tiered pricing. Pair: $1232.50, Triad: $1657.50, Quad: $2125, Extra Person: $510

Price: You will be invoiced by CIESC based on the following tiered pricing. Pair: $1160, Triad: $1560, Quad: $2000, Extra Person: $480

Billing Purchase Order Number*

Billing Purchase Order Address*

Street Address Address Line 2 City State ZIP Code

Email to Send Billing Receipt*

Notifications Consent

Keep Indiana Learning Events and News

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Comments

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