PanGEA workshop registration

PanGEA August Workshop

Immersion for Educators
Participant Information
Name

First NameLast Name
Birth Date

MonthDayYear
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Number

Area CodePhone Number
Cell Number

Area CodePhone Number
E-mail
Name of School or Program
Address of School or Program

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years Teaching Music
Years Teaching Pan
Do you primarily play the steelpan?

YesNo
What is your level of proficiency of steelpan performance/ technical ability?
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
My Products*
prevnext( X )
TT Resident$45.00

Non-TT Resident$90.00

Total $0.00
The payment is ready! It will be completed once you submit the form.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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PanGEA August Workshop