Regent University School of Education

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FREE SEMINAR: Agriculture in the Elementary Classroom

Saturday, November 10, 2012
9:00 a.m. - 12:00 p.m.

Regent University Campus, Classroom Building, Room 107

Although the seminar is free, you must register below to reserve your space.


PERSONAL INFORMATION
Title:
First Name:
Last Name:
Email:

Are you a U.S. citizen?
If no, are you a Permanent Resident?
If not a U.S. Citizen, what is your country of birth?
If not a U.S. Citizen, what is your country of citizenship?
If not a U.S. Citizen, what Visa status do you hold?
Visa Number:

Home Address:
Home Phone:
Place of Employment:
Work Address:
Occupation/Title:
Work Phone:
Please fill out the following information. It is required as a matter of legal reporting requirements applicable to Regent University. It will not be taken into account in any admission or academic decision, nor in the administration of any program at the University.
Gender:
Date of birth:
Ethnic Origin:
How did you hear about this workshop?
If you heard about this workshop from a friend/colleague, please give us his/her name below. That person will be entered in a drawing for a $25 gift card.

REGISTRATION INFORMATION
Note: Regent University reserves the right to change or cancel workshops and semimars, so please call or visit our website (www.regent.edu/mcms) to confirm the location, date and time.