Registration Kentucky Leadership Academy...
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Registration Kentucky Leadership Academy 2015-16 87 C. Michael Davenport Blvd., Frankfort KY 40601 Phone (800) 928-5272 Fax (502) 875-4634 First Name Last Name District School Mailing Address City, State Zip Code Position Email (required) Multiple Registrations - please list all names Payment options AmEx VISA MC DISC Acct # Exp. Date Cardholder Name My billing address is the same as the mailing address. Billing Address, if different than above Dr. Mr. Ms. PO # Check payable to KASA/KLA (print form & mail with check to address above) Purchase Order Credit Card (complete authorization below or call (800) 928-5272 with card information) CCV Code # Questions? Contact Rhonda Caldwell, Executive Director, The Center for Education Leadership ([email protected] ), Rita Muratalla ([email protected]), or Milinda Sosby ([email protected] ) or call the KASA office, (800) 928-5272. To learn more about KLA or other leadership development opportunities, visit www.kasa.org . To Submit by Mail or Fax: Print form to keep a copy for your records and to fax (502) 875-4634 or mail to KASA/KLA, 87 C. Michael Davenport Blvd., Frankfort KY 40601 Credit Card Authorization Card billing address I authorize KASA to charge my above listed account. Signature (typed name ok) > Registration fee includes four regional cadre sessions, statewide events and summer leadership retreat, networking opportunities, up to 48 hours EILA credit, and resource materials that support the work. In Partnership with the Kentucky Department of Education Cadre only option - $299 * Districts registering five or more participants for full KLA may register at the reduced fee of $399 per person. List names of all attendees in box. Work phone Fax Full KLA - $499 (see below if registering five or more) Cadre locations (Subject to change based on registration) For Planning - Please mark your preference Appalachia - Jenny Wiley Bluegrass - Lexington Cumberland - Russell Springs Daniel Boone - Laurel County Hardin County Heartland - Bowling Green Northern - Grant County Ohio Valley - Louisville West - Princeton Highlands - KEDC
Transcript of Registration Kentucky Leadership Academy...
Registration Kentucky Leadership Academy 2015-16
87 C. Michael Davenport Blvd., Frankfort KY 40601
Phone (800) 928-5272Fax (502) 875-4634
First Name
Last Name
District
School
Mailing Address
City, State
Zip Code
Position
Email (required)
Multiple Registrations - please list all names
Payment options
AmExVISA MC DISC
Acct #
Exp. Date
Cardholder Name
My billing address is the same as the mailing address.
Billing Address, if different than above
Dr. Mr. Ms.
PO #
Check payable to KASA/KLA (print form & mail with check to address above)
Purchase Order
Credit Card (complete authorization below or call (800) 928-5272 with card information)
CCV Code #
Questions? Contact Rhonda Caldwell, Executive Director, The Center for Education Leadership ([email protected]), Rita Muratalla ([email protected]), or Milinda Sosby ([email protected]) or call the KASA office, (800) 928-5272. To learn more about KLA or other leadership development opportunities, visit www.kasa.org.
To Submit by Mail or Fax: Print form to keep a copy for your records and to fax (502) 875-4634 or mail to KASA/KLA, 87 C. Michael Davenport Blvd., Frankfort KY 40601
Credit Card Authorization
Card billing address
I authorize KASA to charge my above listed account.
Signature (typed name ok)
> Registration fee includes four regional cadre sessions, statewide events and summer leadership retreat, networking opportunities, up to 48 hours EILA credit, and resource materials that support the work.
In Partnership with the Kentucky Department of Education
Cadre only option - $299
* Districts registering five or more participants for full KLA may register at the reduced fee of $399 per person. List names of all attendees in box.
Work phone
Fax
Full KLA - $499 (see below if registering five or more)
Cadre locations (Subject to change based on registration) For Planning - Please mark your preference
Appalachia - Jenny Wiley Bluegrass - Lexington
Cumberland - Russell Springs Daniel Boone - Laurel County
Hardin County Heartland - Bowling Green
Northern - Grant County
Ohio Valley - Louisville West - Princeton
Highlands - KEDC
