Learn How Science & Literature are a Great Team!Learn Science the Easy Way Through Authors Who Love it the Most

Saturdays, October 13 & November 10, 2012
9:00 a.m. - 3:00 p.m.

To register, please complete and submit the following online form.

Space is available on a first come, first served basis.
Each individual participant will receive an email confirmation as soon as is possible after receipt of registration forms. Please be patient.

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

Are you a U.S. citizen? Yes No
If no, are you a Permanent Resident? Yes No
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:	Male Female
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.
WORKSHOP INFORMATION
You may regsiter to take the workshop only ($99 registration fee) or to take the workshop for graduate credit ($200 registration fee). Please select the appropriate amount below: Learn Science the Easy Way Workshop only ($99) worth 10 License Renewal Points One graduate credit ($200) worth 30 License Renewal Points
REGISTRATION INFORMATION
Submitting this form indicates that I am agreeing to be registered for the following listed workshops/courses and that I take full financial responsibility unless a written request to withdraw is received seven days after the start date of the courses and the written request is granted by the Dean. Note: Regent University reserves the right to change or cancel courses, so please call or visit our website (www.regent.edu/education) to confirm the location, date and time of your course prior to the first day of class.