PanGEA workshop registration

PanGEA August Workshop

Immersion for Educators
Participant Information
Name

First Name Last Name
Birth Date

Month Day Year
Gender

Male Female
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Number

Area Code Phone Number
Cell Number

Area Code Phone Number
E-mail
Name of School or Program
Address of School or Program

Street Address

Street Address Line 2

City State / Province

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

Yes No
What is your level of proficiency of steelpan performance/ technical ability?
Emergency Information
Emergency Contact's Name

First Name Last Name
Relationship
Phone Number

Area Code Phone Number
Alt. Phone Number

Area Code Phone Number
My Products *
prev next ( X )
TT Resident $ 45.00

Non-TT Resident $ 90.00

Total $ 0.00
loading smart payment buttons...

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.
Should be Empty:

PanGEA August Workshop