2017-2018 Base Camp and Leadership Summit Application Please complete this registration form. Questions? Please call 404-401-6613, or e-mail Patty Heitmuller at firstname.lastname@example.org. CONTACT INFORMATIONDistrict Name* Superintendent Name* Superintendent Email* Contact Name* Contact Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*REQUESTED SEATS AND PREFERRED COHORT DATESThe value of each seat is $3,000. GLISI awards a per-seat credit of $750, making the price of attendance $2,250 per participant. # Seats*Enter the number of cohort seats requested (minimum of 5) in # Seats Price: $2,250.00 Quantity: Your district will receive an invoice upon registration. Please provide contact information for invoicing in the spaces below. Invoicing Contact Name* First Last Invoicing Contact Email* Invoicing Contact Phone*Please indicate your district’s preferred cohorts in the boxes below (1 = 1st choice, 2 = 2nd choice, 3 = 3rd choice)*Cohort 52 (September 18-20 & November 6-8, 2017)Cohort 53 (October 16-18 & December 4-6, 2017)Cohort 54 (January 8-10 & February 26-28, 2018) Note: Cohorts will only be offered if a minimum of 120 participants enroll.Financial Hardship*(If the registration fee will prevent you from attending, please use this space to provide a brief narrative explaining your financial hardship. Additional scholarship assistance may be available.)DISTRICT ALIGNMENTPlease provide a brief overview of how attending Base Camp and Leadership Summit aligns with your district's overall improvement plan.*What outreach methods influenced your registration?*Select all that apply: Brochure or Postcard Outreach from GLISI Staff Facebook Twitter Website Colleague Referral Other Please provide a brief explanation*SUGGESTED DISTRICT COMMITMENTS & TIPS ON SELECTING TEAM MEMBERSClick here to download and read the "Suggested District Commitments" and "Tips on Selecting Team Members." CANCELLATION POLICYYour district will be invoiced for the registered number of seats, and all invoices must be paid in full by September 14, 2017. Cancellations or reductions to team size must be made in writing no later than August 14, 2017. Please note that reserved seats are valid for the 2017-18 cohort season.SUPERINTENDENT AUTHORIZATIONCheck the box next to each statement to verify that the Superintendent has reviewed and agreed.* The Superintendent has read the "Suggested District Commitments" and "Tips for Selecting Team Members" above. The Superintendent agrees to adhere to those guidelines to support the success of our Base Camp/LeadersSummit team/s in leading systemic improvement. The Superintendent has read the cancellation policy above. CaptchaPlease fill in the combination of text or numbers you see below!