PO Box 718 • Medina, WA 98039-0718
(800) 260-8180 • Fax: (425) 453-4103
www.iedseminars.org • info@iedseminars.org
PGT0F1-HOU

Seminar Registration Form

Practical Routines, Engaging Activities and Motivating Games to Strengthen Your PHYSICAL EDUCATION PROGRAM (Grades K-8)
HOUSTON, TX, November 12

Pricing Information

Standard Price: $279.00

Group Price: $259.00     Register 3 or more participiants for this seminar at the same time to receive discount.

Group registration?       List additional registrants on a copy of this form.

Personal Information
Ms. Mrs. Mr.   First Name: _________________     M.I. ___     Last Name: ______________________

Position: _________________________________      Grade Level ___________

Priority Code
Important! It is important that you fill in your Priority ID Code from your brochure, even if it was not addressed to you. It is the six digit number on the mail label next to the word "ID".
I have my brochure Priority ID Code: _____________
I don't have my brochure with me
I did not receive a brochure

Your School

School Name:     _________________________________________     School Phone:    ( _____ ) _____ – ________

School Address: _________________________________________     City/State/Zip:    _______________________

Home Address

Home Address: __________________________________________     City, State, Zip: ________________________

Home Phone:   ( ______ ) _______ – __________     E-mail Address: ______________________________________

Payment Information

Payment Method: Credit Card   Check   School or District P.O.   Bill Home   Bill School

Credit Card Information Visa  Mastercard  Discover

Cardholder's Name: _____________________________________________________

Card Number: ____________________________    CVV Number (on back of card) _______

Billing Zipcode: _____________    Expiration Date: ____ / ____

Purchase Order Payment

Purchase Order Number: _____________________________________