Open Enrollment Institute Registration

* required information
Legal First Name:*
Legal Middle Name:*
Last Name:*
Gender:* Female   Male  
Birth Date:*(mm/dd/yyyy)
Institute Choice and Session Dates:* Smart Women, Strong Voices: May 14-15, 2017
Grade Level:*
Address Line 1:*
Address Line 2:
ZIP/Postal Code:*
Cell Phone:
How did you learn about this opportunity? (Be specific, please):*
Method of transportation:*
If you are located outside a 50-mile radius, will you require assistance with flights?:* Yes
If you are located outside a 50-mile radius, will you require hotel accommodations for one night?:* Yes
If flying, please identify the departing airport closest to you:
Do you have prior experience in the topic area of the institute?:*
What are your plans to apply the learning after you leave?:*
Will you require any special assistance?:*
Simon Wiesenthal Center Updates: Yes
Assurance Statement
By submitting this registration form I agree to the following:* I understand that if I am registered for this open enrollment institute, I am making a commitment to attend and participate fully in the two-day course. I will also submit post-session evaluation forms as required.
Travel and hotel accommodations will be arranged and provided for participants traveling 50 miles or more. Please Note: Once your request is received we will send you a confirmation letter with program details. Your registration is not complete until you receive a confirmation letter from our office.

PLEASE NOTE: Once you press the submit button, you will be taken to an automatic confirmation page. Please do not close your browser prior to this confirmation appearing, as it will cancel your submission.

This is only a confirmation that your registration has been submitted, not a confirmation of your program.

We will send you confirmation materials upon review of your registration info. If you do not hear from us please contact to confirm that your registration was submitted.

We recommend printing or saving the contents of this form for your records, in case of submission processing error.


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