Online Event Registration Form

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_____December 1 – 19, 2008
High School Students in College-Based Online Learning

_____January 26 – February 13, 2009
Students with Disabilities in Online Education: Online Only Institutions

_____February 17 – March 6, 2009
Students with Disabilities in Online Education: Traditional Institutions, Nontraditional Classrooms

Applicant Information

Name:_____________________________________________________________
Address:___________________________________________________________
Telephone Number:__________________________________________________
Email Address:______________________________________________________
Institution:__________________________________________________________
Position/Job Title:____________________________________________________

________We are from a Traditional Institution and are submitting payment for full tuition of $1000 for our team. (Please attach a copy of this form with contact information re: additional team members)

OR
______ We have attached the discount coupon from DCCOL. We are from a Traditional Institution and are submitting payment for the discounted tuition of $800. (Please attach a copy of this form with contact information re: additional team members)

OR
______ We are from an Online Only Institution or High School and would like to include a team for the training (someone from disability services and someone from distance learning/technology). We are submitting payment for the team in the amount of $1000. (Please attach a copy of this form with contact information re: additional team members)

OR
______We have attached the discount coupon from DCCOL.  We are from an Online Only Institution or High School and are submitting payment for the discounted tuition of $800 for our team of two or more. (Please attach a copy of this form with contact information re: additional team members)

OR
________I am submitting payment for full tuition of $750.

OR
______I have attached the discount coupon from DCCOL. I am submitting payment for the discounted tuition of $600.

If you have a disability, and may have need for accommodation in order to fully participate, please contact JaneJarrow@aol.com
FAX (270) 477-9450 with proof of payment
or MAIL with check, registration form and coupon to:

DCCOL
2938 Northwest Boulevard
Columbus, OH 43221

The Tax ID# association with any registration/payment is 20-8907088
For further information regarding payment/invoices/etc. contact Rick at 614-370-1780.