MiraVia


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Leading Groups

Effective Strategies for Building Professional Community

An Institute for Leaders and Learners

Featuring Laura Lipton and Bruce Wellman

November 3rd - November 5th, 2010, Simsbury, Connecticut

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 Address 2:

Work City: *

State/Providence: *

Zip/Postal Code: *

Work Country: *

Home Address:

Home City:

State/Providence:

Zip/Postal Code:

Home Country:

Work Phone: *

() - x

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):	$400.00 per participant ($375.00 if paid in full by 09/17/10)
	Individual registration:	$450.00 per participant ($425.00 if paid in full by 09/17/10)

Pay by Credit Card:

Visa

MasterCard

Discover

American Express

Card #:

Exp. Date (MM/YYYY):

Name as it appears on card:

Billing Address:

Same as Home

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.

	Pay by Check:
	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.

	Pay by Purchase Order:
	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: $425

Lodging and meal package:
Registration for the lodging and meal package is made directly with the Simsbury Inn,
ph: 860-651-5700 fax: 860-651-8024. www.simsburyinn.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 September 15th, 2010 - Full Refund

September 16th - October 15th 2010 - 50% Refund

After October 15th, 2010 - No Refunds

* Please note this policy applies to the seminar only. Check with the hotel and airlines for their policies.