Registration Form Complete the following information to reserve your place at the 2015 PBL Math Teaching Summit from July 16-19, 2015. Please print out this form and mail it with a check made out to Deerfield Academy for $260.00 for on-campus registration and $160.00 for commuter registration. Please write “PBL” on the memo line. Carmel Schettino, Director PBL Math Teaching Summit 7 Boyden Lane PO Box 87 Deerfield Academy Deerfield, MA 01342-0087 Complete one registration per person attending the summit. Please print clearly. FirstName___________________________________________LastName________________________________________ Gender Male________ Female ________ Years of Experience with PBL_______________________________ School_________________________________________________________________________________________________________ School Type
Public___________ Independent______________ Charter_____________ Other _______________
Preferred Mailing Address (can be school or home (please circle one)) Street ___________________________________________________________________________________________________________ Town_______________________________________________________State______________________Country_______________ ZIP________________________________ Contact Information: Home Phone ______________________________________ Cell Phone __________________________________________ Work Phone __________________________________________ Email Address you wish to be published in participant list:_____________________________________________
Special Interest Group Rankings: Rank the SIGs according to your preference of which you would most like to discuss. 1=most preferable and 4=least preferable. A – Assessment Methods (including Metacognitive Journal writing and SBG) B – Use of Technology C – Curriculum Development/Adaptation D – Dealing with Obstacles Housing: Will you be staying on campus? Yes ____ No______ Do you have any special mobility needs? Yes ______ No_____ If yes, please explain:
All meals will be provided on campus, including breakfast on Sunday morning before departure. Please arrange for shuttle service from Bradley Airport to Deerfield Academy for your arrival and departure. Some local shuttle services are: www.seemoshuttle.com or http://www.valleytransporter.com/ or http://www.ambassadortaxicab.com/
Please send registration and payment by April 30. Registration is on a first-come-first-serve basis until conference is at housing capacity. Once full, refunds will be given. Cancellations with refund only until June 1, 2015.
Waiver and Hold-Harmless Agreement PBL Math Conference at Deerfield Academy 7/16 – 7/19/15 I, the undersigned _________________________________ (Print Name), in consideration for the use of Deerfield Academy’s facilities (other than the Fitness Center), on behalf of myself, with full knowledge, agree to release any and all claims and agree to hold harmless and indemnify Deerfield Academy, its Board of Trustees, officers, agents, employees, and volunteers from any and all past, present, and future claims suffered by any person due to any cause including but not limited to negligence, breach of contract or breach of warranty, including reasonable attorney’s fees and cost, which arises from, or relates to, the individual’s use of Deerfield Academy’s facilities. This agreement shall be construed pursuant to Massachusetts law and jurisdiction shall be in Franklin County, Massachusetts. AFTER HAVING CAREFULLY READ, AND BY SIGNING THIS AGREEMENT, I UNDERSTAND IT TO BE A LEGALLY BINDING INSTRUMENT.
_______________________________________________ Signature of Individual over the age of 18
Individual’s Name (Print):