Model Schools Registration Form

Model Schools Registration Form

1.    Send form by FAX (518-456-9287), mail or e-mail to: Capital Region BOCES - NERIC, 1031 Watervliet-Shaker Rd, Albany, NY 12205
      Attn: Kim Greiner (kgreiner@gw.neric.org)
2.   Forms must arrive at least 10 business days before the start date of the course!!!
3.   Use one form per individual. Please include COMPLETE home information.
4.   Confirmations will be given via email, but you should keep a copy for yourself.
5.   IF YOU CANNOT ATTEND A CLASS, PLEASE CALL TO CANCEL – THERE MAY BE SOMEONE ON THE WAITING LIST!!!!!!!!

Name: ________________________________ District: _________________________________ Building: ____________________________

Work Phone: _______________________ Fax: _______________________ Grade level/subject taught: _________________________________

Email Address: __________________________________________________

Home Address: ___________________________________________ Home Phone: ____________________________

Home City, State, Zip: __________________________________________

Name of Session Location Fee Date(s)/Time of Session
(if NOT a Model Schools District)

_________________________     ___________________     ______________             _______________________
_________________________     ___________________     ______________             _______________________
_________________________     ___________________     ______________             _______________________

6. Payment Options: (if NOT a Model Schools District)

Check enclosed if not a Capital Region BOCES Model Schools District (district check preferred)
I authorize NERIC to bill the School District named above for this training workshop because our district does not participate in the Model Schools Service

Authorized Signature-Superintendent/Business Manager (required ONLY for non-members)

Signed ___________________________________ Title _____________________

FOR BOCES USE ONLY

1. Confirmed ________ 2. Bill # ________ 3. Payment 4. Amount