2021-2022 Base Camp and Leadership Summit Application 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 estimated value of each seat is $2,900. GLISI awards a per-seat credit of $200 making the price of attendance $2,700 per participant. # Seats*Enter the number of cohort seats requested (minimum of 5) in # Seats. Price: $2,700.00 Quantity: Please indicate cohort preferences in the boxes below (1 = 1st choice, 2 = 2nd choice, 3 = 3rd choice, 4 = 4th choice)*Cohort 61 (June 14–18)Cohort 62 (Sept 20–22 & Nov 8–10)Cohort 63 (Oct 11–13 & Dec 6–8)Cohort 64 (Spring 2021 Dates TBD) You 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*Preferred method of invoicing*Invoice upon confirmation of registrationInvoice on March 1 (for Cohort 61)Invoice on July 1 (for Cohorts 62 - 64)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.)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*SUGGESTED DISTRICT COMMITMENTS & TIPS ON SELECTING TEAM MEMBERSClick here to download and read the "Suggested District Commitments" and "Tips on Selecting Team Members." CANCELLATION POLICYGLISI will confirm your reservation pending seat availability upon receipt of this form and 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 2021-2022 cohort season. Cancellations, reductions in team size, or requests to adjust invoice terms should be sent to email@example.com by April 30, 2021.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/Leadership Summit team/s in leading systemic improvement. The Superintendent has read the cancellation policy above.