Columbus Boot Camp Registration Form

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_____ December 3 - 4, 2008
Students with Disabilities in Online Education: Online Only Institutions

_____ December 8 - 9, 2008
Students with Disabilities in Online Education: Traditional Institutions, Nontraditional Classrooms

_____ March 9 - 10, 2009  
Students with Disabilities in Career Colleges and Proprietary Institutions

Applicant Information

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

________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.
OR

______ We are bringing a team to 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: second team member)

OR
______I have attached the discount coupon from DCCOL. I am submitting payment for the discounted tuition of $800 for our team of two.

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.