Registration Information

1. Fill In all the fields in this form
2. Click the "Submit" button at the bottom
3. Wait for your confirmation email, which you should receive within 2 business days

* ISDN connections will require a bridge.

• If you are in the Indiana AVS system, please go to the following site to order your bridge: http://www.ihets.org/forms/va_video_certification/index.html
• If you do not have access to a "free" bridge, then there will be an Additional Charge of $50 per hour program for an ISDN connection that we will arrange.

Primary Contact Person Information
Name:
Phone:
Email Address:
School/Group Information
School/Group Name
Teachers Name(s)
Teachers Phone:
Teacher Email Address:
Grade Level(s):
Number of Students:	(max. of 30 students per session)
Special Needs:
Program Information
Program:	Faculty Presentation* Africa's Lake Chad Region Bon Appetit Bridging Forces Chemistry Capers Chopstick China Ecology Exploration The Gene Scene Initial Incision Jump Into Japan Magnet Mania Magnifico Mexico My Amazing Body Notice the Netherlands Peruse Peru Simply Marvelous Machines To the Moon and Beyond Native American use of Bison Animal Awareness Animal Families All About Birds! All About Reptiles! All About Mammals! Your Wild Backyard Endangered Animals
Date and Time of Program: (1st Choice)
Date and Time of Program: (2nd Choice)
Date and Time of Test Connection	If at all possible, please pick a Monday date to conduct your test.
Your Time Zone
Technical Contact Information
Technical Support Name:
Phone:
Email:
Type of Connection:	IP ISDN (Requires a bridge)
Phone number during videoconference (if there are connection problems)
Other Questions/Comments:
Billing Information
Billing Contact:
Billing Address:
Billing Phone:
Billing Fax:
Kit Shipping Information
Name and Address: