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2. school

Conference Registration
North Carolina Center for Afterschool Programs
A program of the Public School Forum of NC
Annual Statewide Conference, March 23-25, 2015
Greenville Convention Center, Greenville, NC
Connecting the Dots To Expanded Learning
General Information: Please type or print all of the requested information (one form per person).
Name (Dr./Mrs./Ms./Mr.) ________________________________________________________________________________
Position _____________________________________________________________________________________________
Organization _________________________________________________________________________________________
Mailing Address ______________________________________ City ___________________ State_______ Zip __________
Work phone # ________________________________________________________________________________________
County ________________________________
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Email address_______________________________________________
Check this box if you are staff of or attending SYNERGY as part of a 21st Century Community Learning Center
program.
Registration Information
Please see below for payment instructions and specific conference information.
Early Bird Registration Fee (Afterschool and expanded learning practitioners, non-profits, LEAs, county or state representatives)
 $150.00 (The window for this registration is January 10-31, 2015)
Early Bird Registration Fee (Commercial Groups)
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$250.00 (The window for this registration is January 10-31, 2015)
Regular Registration Fee (Afterschool and expanded learning practitioners, non-profits, LEAs, county or state representatives)
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$175.00 (The window for this registration is February 1-March 20, 2015)
Regular Registration Fee (Commercial)
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$275.00 (The window for this registration is February 1-March 20, 2015)
Late Registration/Onsite Registration (As of March 20, regular registration will be closed. Any registration received after this time or
completed on-site will cost $210.00.)
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Check the box if you are ONLY attending the DPI 21 CCLC Semi-Annual Statewide Meeting (DIRECTORS ONLY), Tuesday,
March 24, 2:15pm-5:00pm.
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 ONLY attending 21 CCLC Meeting
Check the box if you are a community college or university representative
 I represent a community college or university
Check the boxes below that indicate an NCCAP research project on which you participate:
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MECS
USTA Tier 1 or Tier 2 (ACE)
Get Stemulated
2014 Leadership Institute
None, but I am interested in participating
Check the boxes below that indicate if you work in the areas of:
 Evaluation
 Research
This year’s fee based Continuing Education Unit (CEU) session requires advanced registration and an additional fee. It has limited
availability.
 Building Leaders: The Responsible Person; March 23, 8:30am-12:45pm,$40; limited to 50 people
Meal Selections: Complimentary breakfast is provided daily at your hotel. Please check only those you plan to attend:
 March 23, Opening Session (Snack)
 March 24, Luncheon
 March 24, Black Tie Gala Event
 March 25, Closing Lunch
 No Meals
How many years have you attended the Synergy Conference?
Special Requests: Please list any dietary restrictions and or special needs (sign language interpreter, etc.)
Check All That Apply
 I am interested in volunteering as a Hallway Facilitator *Help participants find a session location
 I am interested in volunteering as a Session Host *Introduce workshop presenters, gather evaluations, make
announcements, help speakers with tasks
Check All That Apply
 I do NOT want my contact information shared on the public distribution list
Payment Information
This registration form allows you to make payment online through PayPal to the Public School Forum of NC. If you do not wish to
pay online, a check can be made payable and mailed to the Public School Forum of NC with or immediately following registration.
You can also pay by phone with your credit card (VISA or MasterCard only) to our Finance Manager, Rhonda van Dijk. For
questions or concerns, please contact Tracey Greggs, NC CAP Program Coordinator, at tgreggs@ncforum.org. Payment can be
sent to the following address:
Public School Forum of NC
Tracey Greggs
3739 National Drive, Suite 100
Raleigh, NC 27612
CANCELLATION POLICY: Cancellations received in writing prior to February 20, 2015, will be refunded by check or through PayPal
after March 27, 2015, less a 20% administrative fee. No refunds will be made for cancellations after February 20, 2015.
(Substitutions may be made at any time!)
The federal ID number for NC CAP is 58-1654064.Please note hotel rooms must be booked through the Hilton Greenville by
February 20, 2015. Please call 252-353-3044 for reservations or register online at http://bit.ly/1DqCL4C . Mention code "PSF" for
the discounted room rate of $120.
Discounts
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 Group of 5, pay for 4, get 5 at no cost (Indicate on registration form of 5 person)
 Session Presenter (no registration cost)
 DPI staff (no registration cost)
 Public School Forum/NC CAP staff (no registration cost)
 Speaker (no registration cost)
 Planning committee (no registration cost)
 NC CAP Board
 I received a scholarship to attend
Payment
 Check Check #
 PayPal
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By Phone