Learning Center
Plans & pricing Sign in
Sign Out

baltimore registration form for webpmd


  • pg 1
									                                                 Advance Registration Form                                                                   NSTA Area Conference
                                                                   (See Registration Instructions on reverse.)                                 Baltimore, Maryland
                                                         You can also register online at                             November 2–4, 2006
 ❐ I have already registered for the BALTIMORE conference and wish to add tickets.                       ❐ This is my initial registration for BALTIMORE.

Membership Status
   ❐ I am a member of NSTA. Member ID # ___________________________________
   ❐ I am not a member of NSTA but wish to join. I have included my membership application* and dues with my registration payment.
   ❐ I am not a member of NSTA.
       *see attached

Personal Information               Please print or type. Information with * will appear on your badge.       ❐ Check for no e-mail from exhibitors.
   First Name* ____________________________________                  MI* __________         Last Name* __________________________________________________
   Job Position/Title* ________________________________________________________________________________________________________________
   Name of Institution/Affiliation* ______________________________________________________________________________________________________
   Work Mailing Address _____________________________________________________________________________________________________________
   City* _______________________________________                   State/Province* _____________             Country _____________________              Zip ________________
   Home Mailing Address _____________________________________________________________________________________________________________
   City ________________________________________                   State/Province ______________             Country _____________________              Zip ________________
   I prefer to receive mail at: ❐ Home       ❐ Work
   Daytime phone _________________________              Fax _____________________________ E-MAIL ______________________________________________
   Name of spouse/guest attending conference with you ______________________________________________________________________________________
   Name(s) of children attending conference with you (high school age and under register for free) _______________________________________________________

   ❐ Check here if you need SPECIAL ASSISTANCE due to a disability. Describe on extra sheet and attach, including evening phone number if applicable.

  Disciplines (check all that apply)        Position (check all that apply)          Grades (check all that apply)                  Institution (check all that apply)
  ❐   Earth Science    ❐ Computer Sci.      ❐    Teacher             ❐ Student       ❐   PreK–K          ❐   8th Grade              ❐   Public School ❐ 2-year College
  ❐   Biology          ❐ Tech. Education    ❐    Professor           ❐ Scientist     ❐   1st Grade       ❐   9th Grade              ❐   Private School ❐ 4-year College
  ❐   Chemistry                             ❐    Dept. Head/Chair ❐ Consultant       ❐   2nd Grade       ❐   10th Grade             ❐   Laboratory       ❐ Graduate School
  ❐   Physics                               ❐    Principal                           ❐   3rd Grade       ❐   11th Grade             ❐   Business         ❐ Retired
  ❐   Environmental Science                 ❐    Supervisor/Coordinator              ❐   4th Grade       ❐   12th Grade             ❐   Informal Education
  ❐   Physical Science                      ❐    Administrator                       ❐   5th Grade       ❐   College                ❐   Home School
  ❐   General Science                       ❐    Professional Develop. Provider      ❐   6th Grade                                  ❐   Library
  ❐   Other ____________________            ❐    Other ____________________          ❐   7th Grade                                  ❐   Other____________________

Registration Fees                                              Ticket Orders See reverse for details.                            Payment
Please circle correct amount.      Earlybird Advance Full Rate
                                                                                                                                 Registration Fee                 $ ________
                                    9/22/06 10/6/06 After 10/6 Short Courses/Symposia/ELL Confer-
Two to Three Days                                              ence                                                              Spouse/Guest Fee                 $ ________
                                                               Event #   Qty. X Price   = Total                                  Membership Fee (form attached) $ ________
❐ Current NSTA member or applicant   $120     $130     $155
                                                               ______    ____   ______      ______
❐ MAST member #_____________         $120     $130     $155                                                                      Tickets (from Ticket Orders)     $ ________
                                                               ______    ____   ______      ______
❐ Nonmember                          $194     $204     $229    ______    ____   ______      ______                                                    Total Due: $ ________
❐ Retired NSTA member #__________ $65         $75       $95
                                                                                                                                 I am paying by:
❐ International (except Canada)       $65     $75       $95    Social Functions
                                                               Social #  Qty. X Price   = Total                                  ❐ Check #_____ (payable to ‘National Science
❐ Full-time student                   $55     $65       $85
                                                               ______    ____   ______      ______                               Teachers Association’ in U.S. funds)
One Day Only–Check Day: ❐ Thu ❐ Fri                            ______    ____   ______      ______
❐ Nonstudent (member or nonmember) $105                        ______    ____   ______      ______                               ❐ Credit Card:
                                              $110     $130
                                                                                                                                    ❐ AMEX ❐ Discover ❐ MasterCard ❐ VISA
❐ Full-time Student                        $25        $30         $45
                                                                           Field Trips                                               # _______________________________
Last Day Only–Saturday                                                     Trip #     Qty. X Price  = Total
                                                                                                                                    Expiration Date:_____________________
❐ Nonstudent (member or nonmember)                                         ______     ____   ______   ______
                                           $75        $80         $90                                                               Signature:_________________________
                                                                           ______     ____   ______   ______
❐ Full-time Student                        $25        $25         $45
                                                                           ______     ____   ______   ______
                                                                                                                                 ❐ School Purchase Order (copy attached):
❐ Nonteaching Spouse/Guest                 $45        $55         $70                                                               PO No. ___________________________
  (enter name above)                                                                                 Subtotal ______

Mail or fax your completed form with payment to: National Science Teachers Association, Conferences Department, PO Box 90214,
Washington, DC 20090-0214, FAX: 703-243-3924, or register online at

Registration Instructions                                                              You must register by the advance deadline to receive your badge, tickets,
                                                                                       and confirmation in advance of the conference. If you mailed or faxed your
This form is for the use of conference participants only. Individuals register-
                                                                                       registration before the advance deadline and if by October 17 you have
ing to conduct business must contact the Exhibits Department to register as
                                                                                       not received your confirmation packet, call NSTA conference registration at
a Non-exhibiting Industry Representative.
                                                                                       703-243-7100 or 800-328-8998 or e-mail
Each registrant (except nonteaching spouse) must submit a separate
                                                                                       If your registration is postmarked after the advance deadline you will be
registration form. Do not send duplicate registrations—if you fax your
                                                                                       charged at the full on-site rate and your confirmation may not be mailed to
form, do not also mail the form.
                                                                                       you before the conference. Pick up your confirmation, badges, and tickets
Registration fees cover all nonticketed conference activities and entry to the         on-site at the Problem Solving Counter in the NSTA Registration Area.
Exhibit Hall. Fees do not cover ticketed events, meals, lodging, or transporta-
tion other than NSTA-contracted shuttle service.                                       Ticketed Events
                                                                                       Information on ticketed events can be found in this program and on NSTA’s
Registration Rates                                                                     website ( Tickets are available on a first-come/first-
The member rate:                                                                       served basis. If you are registered for the full meeting (two–three days), you
Only those individuals listed below may register at the NSTA member rate:              may purchase tickets for any available event. If you are registering for one day
                                                                                       only, you may buy tickets only for those events that take place on the day for
• Current NSTA members                                                                 which you are registering.
• Nonmembers who submit an NSTA membership application along with                      There are two prices for ticketed events: the advance price and the on-site
  the registration form                                                                price. To qualify for the advance price, your registration with ticket purchases
                                                                                       must be postmarked or faxed by the advance registration deadline of October
• Members of the Maryland Association of Science Teachers (MAST)
                                                                                       6. Tickets are nonrefundable.
The retired member rate:                                                               If you have already registered for the Baltimore conference, you may use this
NSTA members who are fully retired and have been an NSTA member for at                 form to add tickets. Check the box "I have already registered for the BALTIMORE
least five years may register at the retired rate.                                     conference..." at the top of the Registration Form and list the tickets you wish
The international rate:                                                                to purchase under “Ticket Orders.” Be sure to provide your name and address
Attendees from countries other than the U.S., U.S. territories, and Canada             and your NSTA member number if applicable.
may register at the international rate.                                                You cannot add tickets to a previous registration online (even if you originally
The student rate:                                                                      registered online). You must submit a new form.
Full-time students 18 years of age or older may register at the student rate
if the registration form is accompanied by a copy of a current university ID           Submitting Your Registration
or a letter from the university indicating fulltime enrollment.                Payment for registration and membership (if attaching membership
                                                                               application) must be included with your registration form. Forms received
Registration to attend a National Science Teachers Association (NSTA)          without payment will be returned unprocessed. Payment may be made by
conference means permission is granted to NSTA to use attendee’s photo in credit card, check, or purchase order from your school or school district (attach
NSTA marketing and promotional pieces about the Association for an             forms for all registrants). Mail or fax your completed form with payment to:
indefinite period of time. Promotional pieces include, but are not limited to,
printed brochures, reports, postcards, and flyers, as well as online uses such             National Science Teachers Association
as postings on the NSTA website and e-mail blasts.                                         Conferences Department
                                                                                                    PO Box 90214
Spouse/Guest/Children Attending Conference                                                          Washington, DC 20090-0214
                                                                                                    FAX: 703-243-3924
with You
Your nonteaching spouse/guest and children must be registered in order to
visit the Exhibit Hall but do not need to submit separate registration forms.
                                                                                       Refund/Cancellation Policy
Please provide their names on your own registration form. Children of high             Refund requests must be in writing and must be postmarked 10 days before
school age and under can be registered for free. A fee is required for your            the conference. Badge materials must be returned with refund request.
spouse/guest. College students and teaching spouses must submit separate               Registration cancellations are subject to a $20 processing fee. Ticketed
registration forms and payment.                                                        events are nonrefundable.

Earlybird/Advance Deadlines
                                                                          Contact NSTA conference registration at 703-243-7100 or 800-328-8998,
Registrations postmarked (or faxed) by the earlybird deadline of Septem-
                                                                          or via e-mail at For general information on the Baltimore
ber 22 or the advance deadline of October 6 have substantially lower fees
                                                                          conference or to register online, visit our website at
than full on-site registration.

                      Become an NSTA member and save when you register for 2–3 days!
                                 Simply complete a membership application and include it and your payment with your registration form.
Maximize Your Potential in the Classroom—
Join NSTA Today and Save!
Gain year-round access to the latest news and information affecting science education.

1.     Membership Options Each membership op-
       tion listed below includes one journal.
                                                                    2.           Contact Information (please print)

       ❏ Individual Membership—$74/yr.                                           Name ______________________________________________________________

       ❏ New Teacher—$32/yr. Teachers who are in their first                      Title _______________________________________________________________
           three years of teaching. Send a copy of your teaching                 Institution __________________________________________________________
           certificate or a letter from your administrator.
                                                                                 ❏   Home                ❏     Work
       ❏ Retired—$32/yr. Science educators who are fully re-
           tired and have been an NSTA member for at least five                   Address ____________________________________________________________
           years.                                                                Address ____________________________________________________________
       ❏ Student—$32/yr. For full-time students only. Include                    City ______________________________ State _______ Zip ________________
           proof of current registration with your payment.
           Instructor must sign here:                                            Country ____________________________________________________________

                                                                                 Work Phone ________________________________________________________
           _______________________________________________                       Home Phone _______________________________________________________
       ❏ Joint NSTA/NATS—$89/yr. Includes membership in                          Fax ________________________________________________________________
           both Nebraska Association of Teachers of Science and
                                                                                 E-mail ______________________________________________________________
           NSTA (NATS06).
       ❏ Joint NSTA/MAST—$74/yr. Includes membership in                          Have you ever been an NSTA member?
           both Maryland Association of Science Teachers and
                                                                                 ❏   No              ❏    Yes ID# ________________________________________
           NSTA (MAST06).
       ❏ Joint NSTA/USTA—$72/yr. Includes membership in                          ❏   Please remove my name and postal address from the mailing list
                                                                                     NSTA makes available to other organizations.
           both Utah Science Teachers Association and NSTA

3.     MEMBERSHIP JOURNALS Select the journal you
       would like to receive as part of your membership:
                                                                    4.          GRADES (check all that apply)

                                                                                ❏    Pre-K                 ❏   4th Grade           ❏   9th Grade
       ❏ Science & Children—                                                    ❏    Kindergarten          ❏   5th Grade           ❏   10th Grade
           8 times a year; grades K–6                                           ❏    1st Grade             ❏   6th Grade           ❏   11th Grade
                                                                                ❏    2nd Grade             ❏   7th Grade           ❏   12th Grade
       ❏ Science Scope—
                                                                                ❏    3rd Grade             ❏   8th Grade           ❏   College
           8 times a year; grades 6–9

       ❏ The Science Teacher—
           9 times a year; grades 9–12                                          DISCIPLINES (check all that apply)

       ❏ Journal of College Science Teaching—                                   ❏    Earth and Space Science         ❏   Physical Science
           7 times a year; college                                              ❏    Biology/Life Science            ❏   General Science
                                                                                ❏    Chemistry                       ❏   Computer Science
       To subscribe to more than one journal, call NSTA Member                  ❏    Physics                         ❏   Tech Education
       Services at 800-722-NSTA (6782) or 703-243-7100.                         ❏    Environmental Science           ❏   Other______________________

6.     Payment Method—Canadian and international members, please add $10 per journal per year. (U.S. Dollars)
       ❏ School Purchase Order enclosed. PO#_____________________________________
       ❏ Check enclosed, payable to NSTA (U.S. Dollars)
       ❏ Please charge my credit card: ❏         NSTA MasterCard**          ❏   MasterCard          ❏   VISA      ❏   Discover

       Card # _____________________________________________________________________________________ Expiration Date _______________________

       Name on card __________________________________________________________ Signature ________________________________________________

     Four Easy Ways to Join NSTA                                                          Membership dues are subject to change without notice.
                                                                                          *NSTA Reports is distributed to U.S. and Canadian members only.
     1. Visit
                                                                                          ** Use of this card supports the science teaching profession. Call MBNA at
     2. Fax your completed form to 703-243-3924                                           800-847-7378 for more information.
     3. Mail your completed form with payment to NSTA, P.O. Box 90214,
        Washington, DC 20090-0214.
     4. Call NSTA Member Services at 800-722-NSTA (6782) or 703-243-7100.

To top