U.S. Department of State

Please fill out this form completely:

NAME: _________________________________________________________________________
SCHOOL: ______________________________________________________________________
POSITION: ______________________________________________________________________
ADDRESS: ______________________________________________________________________
PHONE: __________________________ 
EMAIL: ___________________________

ACCOMMODATIONS

Housing will be provided at the George Mason University campus, in Fairfax, Virginia. Housing will only be paid for participants for the nights of Sunday, June 24 through Thursday, June 28, with a checkout of Friday, June 29, 2012. Dinners will be provided at Thomas Jefferson HS on Monday and Wednesday and dinner on Sunday will be provided at George Mason University; dinners on Tuesday and Thursday will be on your own. All breakfasts and lunches will be served at Thomas Jefferson HSST.

I plan to stay at George Mason University housing for the following nights:
Sunday, June 24     _____                                    Wednesday, June 27 _____
Monday, June 25    _____                                    Thursday, June 28      _____
Tuesday, June 26  _____

Additional nights can be arranged for $40 a night (participants are responsible for this fee which must be paid in advance of attending the conference).

For purposes of room delegation: __ male __ female

If arrangements can be made, would you be interested in attending the following activity, at a small cost to you, payable at the conference? If interested, please check that you would like to attend:

_____ Play at the Kennedy Center for Performing Arts

TRAINING INFORMATION
Sessions will begin at 9:00 a.m. on Monday, June 25 and end at noon, Friday, June 29, 2012. Once you have been accepted you will receive information regarding lodging, transportation and session details. Please select the strand that best meets your individual needs and interest:

_____ Instructional Integration for Teachers
_____ Real Techies Only!

During the training I would like to have answers to the following question(s):
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Signed _______________________________________ Date ____________________
(Participant)
_____________________________________________ Date ____________________
(School Director)

Please e-mail, fax, or send the completed form by March 16, 2012 to:
Marie Burton, Office of Overseas Schools
U.S. Department of State, Room H 328-SA1
Washington, D.C. 20522-0132
FAX (202) 261-8224
E-mail: burtonmm@state.gov