Registration Form - Regular Mail or FAX

Fall Meeting of the Illinois and Iowa Sections of the AAPT
October 13-14, 2006 - Rock Island High School, Rock Island, Illinois

Name:  ______________________________________________________________________________

Address - line 1:  ______________________________________________________________________

Address - line 2:  ______________________________________________________________________

City, State ZIP: _______________________________________________________________________

Telephone: (________)___________________ Ext.__________ FAX: (_______)___________________

E-mail:  _____________________________________________________________________________

Institution (to appear on your name tag):  __________________________________________________

I would like to do a "Take Five" on ___ Friday afternoon,  ___ Saturday morning, ___ either day.

The title of my Take Five presentation is: __________________________________________________

I will be bringing an item for WITHIT (What in the heck is it?) on ___ Friday, ___ Saturday, ___ either day.
Description Number Unit cost Amount
Faculty registration   $24  
Student registration   $ 5  
Illinois section dues   $ 5  
Iowa section dues   $ 5  

Please indicate if you wish to register for a workshop.
Note:  W1 and W2 are at the same time so you can only register for one of them.
Workshop W1. Robotics in the College and High School Classrooms - Friday 10:00 am - noon      
Workshop W2. Personal Response System - 11:00 am - noon      
Workshop W3. Make It and Take It - Saturday morning   $10  
* Friday evening buffet banquet.  The entrees are chicken, ham and vegetable lasagna.   $16  
* Saturday noon lunch. Circle your choice of
    sandwich (1. Turkey, 2. Ham & Swiss, 3. Tuna Salad, 4. Ham, Turkey and Provolone),
    topping (1. Standard, 2. Standard with onions),
    chips (1. Classic Lay's, 2. Baked Lay's,  3. Harvest Cheddar Sun),
    cookie (1. Chocolate chip, 2. Peanut Butter), and
    drink (1. Sierra Mist, 2. Pepsi, 3. Diet Pepsi, 4. Lemonade, 5. Water).
Note: The standard topping includes lettuce, tomatoes, salad dressing, oil, vinegar and oregano.		   $ 6  

Total fees

  

* The meals are available only to those who have registered by the October 6 deadline.  Please make your check payable to ISAAPT and include it with the registration sent via US Mail.  If registering by FAX or online, the registration amount will be due upon arrival.  Please return this registration form to:  Gary Wolber, Rock Island High School, 1400 25th Ave, Rock Island, IL 61201.  Phone: 309-793-5950 x1327, Fax: 309-793-9866.

Last update: September 21, 2006

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