Summer Institute for Leaders and Learners
Learning-Focused Relationships:
Consulting, Collaborating & Coaching for Professional Excellence
Featuring Laura Lipton and Bruce Wellman
August 11th - 15th, 2008, Niagara, ON

Please complete this registration form and press the Submit button to send us your registration.
Or, if you prefer, print this form and mail or fax to:

MiraVia LLC, 93 Medford St., Arlington, MA 02474, 781 316-8484 Voice, 781 998-0298 Fax.
The information you provide will be used to contact you with further Institute information and to create the participant roster. If you are registering for more than one person, you will be required to enter contact information for all members of your team on the next page. Fields marked with an asterisk are required entries.

First Name: * 
     Mid Init:         Last Name: *   
 
Position:   
School & District/Agency: *   
Work Address: *   
Work City: * 
     State/Providence: *         Zip/Postal Code: *   
 
Work Country: *   
Home Address:   
Home City: 
     State/Providence:         Zip/Postal Code:   
 
Home Country:   
Work Phone: * 
( )  -
      Home Phone:   
( )  -
 
Fax: 
( )  -
      Email: *   
 
 
Method of Payment:
Please indicate your method of payment below. Be sure to fill in ALL fields. Checks and Money Orders should be made payable to MiraVia, LLC and mailed with a printed copy of the summary of registration form to the address provided above. Purchase Orders are also welcome, simply mail or fax a printed copy of the summary of registration form with your PO.
Registration Fees: Team registration (3 or more): $850 per participant
($750 if paid in full by 6/1/08)
  Individual registration: $950 per participant
($850 if paid in full by 6/1/08)

    
 
  Card #:
  Exp. Date (MM/YYYY):  / 
  Name as it appears on card:
Billing Address:    
City/ St-Prov/ Zip-PCd:
  Your information is transfered over a secure connection. However, If you would rather mail or fax your credit card information, you may do so by printing a copy of your summary of registration (final page) and filling in the credit card fields.
    
  Print the summary of registration form provided at the end of this process and mail it with your check or money order to the address above.
    
  Print the summary of registration form provided at the end of this process and mail or fax (781 998-0298) it with your Purchase Order to the address above.
  P.O. #: 
 
Number of Registrants: *
 
Total Payment: $
 

     

Lodging and meal package:
Registration for the lodging and meal package is made directly with White Oaks Conference Centre, ph: 905-688-2550 toll-free: 1-800-263-5766 www.whiteoaksresort.com. Ask for group name MiraVia.
Cancellation Policy:
Should you need to cancel your registration for any reason, our policy is as follows:
  • Up to July 1st, 2008 - Full Refund
  • July 2 - 30th, 2008 - 50% Refund
  • August 1st - 11th, 2008 - No Refunds
* Please note this policy applies to the seminar only. Check with the hotel and airlines for their policies.