First Name:    Last Name:

Address:   City:

State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY   Zip:

Email Address:

Phone Number: 

School/Agency/Employer:  (note: if Sioux Falls School District, please enter SFSD & your school name. ex: SFSD-Hawthorne)

Job Assignment: Teacher Administrator Law Enforcement Social Services Social Worker OT-PT-ST Parent Other

Cost: 2 days = $75       4 days = $125

Which days will you be attending the conference (mark all that apply):

Payment Type:

Credit Card (via PayPal)

 SFSD Building Funds     

 Purchase Order (PO#)

n/a: Law Enforcement 

n/a: Presenter 

Please note: Payment is for the conference only. You may register and pay for graduate credit at the conference.