ICT Registration 2017 Institute for Creative Teaching Registration June 20 - 23, 2017 Your InformationName* First Last School*Email* Enter Email Confirm Email Alternate EmailPlease provide an email address that you will be checking in June. Enter Email Confirm Email Primary Phone*In case we have a problem with your registrationAlternate or Cell Phone*Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code School InformationSchool District*School County*School Phone*Grade*Please tell us what grade levels you teach or are licensed to teach. If you are not currently teaching, please explain.Subject*Please tell us what subjects you teach (e.g., literacy, math, science, P.E., etc.)EmergencyPlease provide a name and phone number in case of emergency.NotesPlease let us know if you have any special needs or concerns.QuestionsRelease*Collaboration and sharing is one of the founding principles of great educational practice. Think 360 Arts reserves the right to publish photographic testimonies and representations of the experiences within the structure of the Institute for Creative Teaching on our social media platforms, and in our marketing materials. I have read and understand these terms. Registration and Fee PaymentRegistration Fees*Regular Registration* - $425.00I am a Think 360 Teaching Artist - $200.00I am a DU Student, registered for CUI 4710 - $0.00*Thanks to our partnership with Denver Arts & Venues, we are pleased to offer 10 scholarships to Denver Public Schools teachers. Interested applicants should email email@example.com PRIOR to registering. Total Amount Due $0.00 Payment Method*Please select your desired method of payment. Where needed, additional information and/or fields will appear.Mail check to Think 360 ArtsPay by Credit CardBill my SchoolI am a DU student and have registered for CUI 4710Please write a check for the Total Amount Due, payable to Think 360 Arts and mail to: Think 360 Arts 135 Park Avenue West Denver CO 80205Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name School Billing Name*Please provide the name, email address, and phone number of your school's financial secretary.School Billing Email* School Billing Phone* This iframe contains the logic required to handle AJAX powered Gravity Forms.