Registration Procedures You may mail this to the address below, FAX it to (785) 5322422 or PHONE (785) 532-5569

or visit https://www.smore.com/qax0 to register securely online. Registration Form (please print) _____________________________________________ Last Name First Name MI _____________________________________________ Position School District # _____________________________________________ School Name and Address _____________________________________________ Billing Address if Different from Above _____________________________________________ Daytime Phone FAX Number e-mail _______________________________________ ____________________________________________ List Special Assistance or Dietary Needs Registration Amount ______ $25.00 ______ $5.00 Parking Permit _______ Paid by District _______ Paid by Registrant

Registration Information _______________________________________ Location & Parking Sessions will be located as follows: The

iCamp iPad Day will be held in Bluemont Hall

on the K-State campus on January 15, 2014. Conference participants intending to park on campus are required to purchase a parking permit. Permits (including the parking garage) are $5 per day and may be purchased by checking the appropriate space on the registration form. Prepayment for permits is required. Parking in the parking garage without a permit is $1.50/hour. Additional parking information will be provided in your registration information. Registration Registration for the Day will begin at 7.30 a.m. The conference will begin at 8:00 a.m. and will conclude at 3:00 p.m. Lunch is included in your registration fee. Space is limited so early registration is recommended. The conference registration fee will be refunded in full (less a $10 administrative fee) if notification is received by 5:00 p.m. on January 10. For questions regarding registration procedures, please call 785532-5569 or toll free to 1-800-432-8222. Special Assistance Kansas State University is committed to making conferences accessible to all participants. A participant in a conference or non-credit program with a disability who needs accommodations or has special dietary requirements should indicate the services needed at the time of registration. If you have further questions please contact Tony Ballard at 785-5322402 or 1-800-622-2KSU. Early notification is requested to ensure that accommodations can be provided in a timely manner.

$ ________ Total Amount

Method of Payment ___________ Check enclosed (make payable to Kansas State University) ___________ Purchase Order enclosed # _______ Photo Release "You may use my photo for educational, news, or promotional purposes including but not limited to marketing materials or the organization's website." ________ Yes ________ No

Roster Release "You may print my name, affiliation, address (US mail/email/WWW) and telephone/FAX number in the roster of participants." ________ Yes ________ No Return this form to:

iCamp iPad Day, Division of Continuing Education, 1615

Anderson Ave, Suite 141, Kansas State University, Manhattan, KS 66502-4098