2012 BuildaBridge Institute Registration Form

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Build Your Skills and Learn to Engage Your Art-Making for Transforming Communities through Education, Therapeutic Art-Making and Community Programming

When
June 6-10, 2012

June 11 Track 1: Psychological First Aid and Arts Relief (Red Cross Certificate provided)

June 11 Track 2: Introduction to Restorative Practices.

Where
Philadelphia, PA, USA

Cost
$575 Registration. $115 for Arts Relief and Intro to Restorative Practices

Email: institute@buildabridge.org

Please complete the entire form. Blank spaces may delay processing. Your responses will be automatically emailed to BuildaBridge for processing.

Personal Information

Last name *

First name *

Preferred Badge name *

Organization Name/Affiliation

Address *

Home Phone *

Mobile Phone

Fax

Email address *

Emergency Contact & Phone *

Specific Meal requirements

None

Vegan

Vegetarian

Other:

Clear selection

Any Special Needs?

Professional & Education Information

Check all that apply

Attending the Institute for the First Time

Attending the Institute as a Returning Participant

Attending the Institute for Undergraduate Credit

Attending the Institute as a MAUS student

Nonprofit professional

Social Service personnel

Communitiy Development Professional

Artist

Congregation Leader

School Teacher

After School Professional

Youth Worker

Alumni

Teaching Artist

Primary Artistic Discipline

Visual Art

Music

Dance

Writing, Poetry, Spoken Word

Drama

Culinary Arts

Other:

How did you hear about BuildaBridge Institute 2012?

Tell us briefly about your work and what you hope to learn at the Institute 2012.

Demographic Information

Demographic information is needed for our reports to the foundations and agencies that provide funds and scholarships for the BuildaBridge Institute. We appreciate your cooperation in supplying this data. It will be treated confidentially and used in reporting according to funding agency specifications.

Select Gender

Female

Male

Clear selection

Select Age

18-24

25-34

35-44

45-54

55 and over

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Ethnic Origin

Annual Income

under $15,000

$15,000-$25,000

$25,001-$35,000

$35,001-$45,000

$45,001-$55,000

$55,001-$65,000

$65,000 and above

Clear selection

Registration

Registration deadline is May 30, 2012. Cost is $575. Early registration before May 15 is $550. Registration includes courses, materials, the Wednesday Barbeque Dinner at the BuildaBridge House and the Alumni Symposium Dinner on Saturday.

Mark your selections below. You will be emailed a confirmation of your selections within two weeks of registering. Payment is due within two weeks of receipt of registration confirmation from BuildaBridge.

Making a payment: INSTRUCTIONS: The most convenient is an electronic funds transfer from your bank. What does this mean? Go to your online banking account and set up BuildaBridge International as a Payee. Use this address: 205 West Tulpehocken Street, Philadelphia, PA 19144. Phone #: 215-842-0428. Send the money from your account as a payment or online check. This is safe and reduces any charges to you or BuildaBridge. Canadian and International residents should contact ncorbitt@buildabridge.org for more information.

Open Institute Registration

Track 1

Track 2

Clear selection

Specialized one day training courses June 11

Registration includes continental breakfast and lunch.

Arts Relief: Registration $115 (begins at 8:30am)

Introduction to Restorative Discipline Practices: Registration $115 (begins at 9:00am)

Clear selection

Are you an Eastern University Arts in Transformation Graduate student? *

Yes

Required

Housing and Meals

The Institute will take place at Arcadia University on the edge of Philadelphia in Glenside, PA. Housing and meals are provided on campus. The cost for the open Institute is:

1. Housing Wednesday though Saturday (4 nights)--$195. Food $125.
2. Housing Wednesday through Sunday (5 nights)--$240. Food $125

Internet is included.

For those who are commuting, the cost is $185 for meals and facility costs.

All payment is due by Wednesday May 30, 2012 and checks should be made to BuildaBridge International. If paying by credit card please add 6% service charge. Payment can be made through PayPal. Please email for instructions to institute@buildabridge.org.

Do you plan to commute to the Institute? *

Yes

Required

Thank you.

Thank you for registering for the 11th annual BuildaBridge Institute for Arts & Transformation. You will receive confirmation of registration within two weeks of registration.

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