Registration Form

PSAYDN Regional Afterschool Summit

A Continuum of Learning: PA Supports the Power of Afterschool
May 28, 2009
Boys & Girls Club of Northeastern PA, Scranton, PA

*Required fields are marked with an asterisk.

Registrant Information

Prefix:

First Name: *

Last Name: *

Suffix:

Job title or position: *

Registering as: *

School district or organization where you work: *

School building where you work, if applicable:

Street Address where you receive business mail: *

Street Address 2nd Line:

City: *

State: *

Zip Code: *

Phone number where we can contact you about this event: *

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Ext

Fax:

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Email address where we should contact you to provide information about this event: *

County: *		Intermediate Unit (required if you are registering from a school):

Special Meal Accommodations
A continental breakfast and lunch will be provided. Please indicate any special meal accommodations.

Vegetarian
Other special dietary needs:

ADA Special Needs Accommodations
Participation by all individuals is encouraged. Advance notice of any special needs will help us provide better service. Please notify us of your needs at least two weeks in advance of the event by contacting Dave kern at the Center for Schools and Communities at (717) 763-1661, ext 200

Registration Fee
This event is sponsored by the Pennsylvania Statewide Afterschool/Youth Development Network. There is no registration fee to attend; however, the conference is only open to residents of the Commonwealth of Pennsylvania.

When you click the submit button, you will receive an email confirming receipt of your registration request and a plain text copy of the information you submitted. The email will be sent to the business email address listed above.