REGISTRATION 2024 Fall BCLS Seat Request Form 2024 Fall Base Camp and Leadership Summit: Seat Request Form Please complete this registration form. GLISI will confirm your reservation pending seat availability upon receipt of this form. Questions? Please e-mail Jennie Welch at [email protected]. CONTACT INFORMATIONDistrict Name* Superintendent Name* Superintendent Email* Contact Name* Contact Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*REQUESTED SEATSBase Camp Dates: Sept. 9-11, 2024 Leadership Summit Dates: Nov. 11-13, 2024# Seats Quantity*Enter the number of cohort seats requested (minimum of 5) in # Seats. Price: $2,800.00 Quantity You will receive an invoice upon registration. Please provide contact information for invoicing in the spaces below. INVOICINGInvoicing Contact Name* First Last Invoicing Contact Email* Invoicing Contact Phone*Preferred method of invoicing* Invoice upon confirmation of registration Invoice on July 1 Statement of 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. Priority for financial assistance will be given to registrations received by May 17, 2024.STRATEGIC ALIGNMENTPlease provide a brief overview of how attending Base Camp and Leadership Summit aligns with your 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* CANCELLATION POLICYGLISI will acknowledge your reservation upon receipt of this form and will confirm registration pending seat availability; GLISI will invoice upon confirmation unless other terms are agreed upon by you and by GLISI. All invoices are due within 30 days of invoice date. Registrations are only valid for the Fall 2024 cohort. Cancellations, reductions in team size, or requests to adjust invoice terms are not guaranteed and should be made in writing by May 17, 2024 with a request to Jennie Welch at [email protected].SUPERINTENDENT AUTHORIZATIONCheck the box below to verify that the Superintendent has reviewed and agreed.* The Superintendent has read the cancellation policy above. Δ
