Register for CEU

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Name*

First Middle Last

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Event Date

Address*

Street Address Address Line 2 City State ZIP Code

Social Security Number

Required for CEUs. Can be provided by phone.

Date of Birth

Required for CEUs. Can be provided by phone.

School District Employed*

School Where You Teach

Email*

Phone*

School or personal phone.

Today's Date

Signature

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Event Date*

20% discount ends July 1, 2022. Registration is $420 after July 1.

Total

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Card Number Expiration Date Security Code Cardholder Name

P.O. Number

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