2019 Open Minds, Open Doors Registration
Please complete all information below to register your school for the Open Minds, Open Doors conference scheduled for Thursday, October 10th at Coe College.

Thank you!
Susie Green
sgreen@gwaea.org

Email address *
School Information
School Name *
Your answer
School District *
Your answer
Our school group will (select one): *
Payment Information
Our school will provide (check one): *
Required
Chaperone Information
In the interest of safety and communication, Grant Wood AEA requires schools to provide at least one (1) teacher or adult chaperone to accompany students to the Open Minds, Open Doors conference. Schools may send as many additional chaperones as needed to support their students. There are 2 payment options for chaperones.

Please review the following chaperone agreement and then complete the questions below.

Chaperone Agreement:
I understand that the chaperone must remain on the Coe College campus during the conference and will be responsible for the following:

□ Check-in at Sinclair Auditorium between 8:30 a.m. and 9:00 a.m.
□ Alert conference staff of student absences on conference day.
□ Check on my students during their workshop sessions, and assist/intervene as needed.
□ Remain with my students during the lunch and learn rotation, encouraging appropriate behavior of the group.
□ Act as emergency contact for my students on conference day.

I have read and agree to the responsibilities listed in the Chaperone Agreement above. *
Required
Anticipated number of chaperones attending from our school *
Your answer
Chaperone First Name *
Your answer
Chaperone Last Name *
Your answer
Chaperone Position/Title *
Your answer
Chaperone Phone Number *
Your answer
Chaperone Cell # (where you can be reached while at Coe) *
Your answer
Do you have health conditions or allergies? *
Are you the appropriate person at your school to receive pre-conference emails and confirmation details? *
If you are not the appropriate person to receive pre-conference communications, or if there is someone else in your building to cc: materials to, please list that person's name and email below.
Your answer
Please indicate your payment option preference. *
If you selected Option 1 above, please indicate your t-shirt size:
If your school will be sending more than one chaperone, please provide additional names, contact info (email and phone), health concerns, and preferred payment option (with t-shirt sizes if applicable) in the text box below. If you will not be sending additional chaperones, write "none". *
Your answer
Selected/Anticipated Students
Please provide below your anticipated list of 7th and 8th grade girls who will be attending the Open Minds, Open Doors conference. List first name and last name.

The cost per student is $15. Financial need scholarships are available for girls who may have difficulties making payment.

Please use the following when identifying girls for this event:
Selection Guidance:
• A maximum of 25 girls per school may register (space permitting)
• NO repeat attendees from previous years
• Consider girls who do not have other enrichment opportunities
• Diversity and all ability levels encouraged
• Consider girls who may not currently be planning to attend college
• Again…diversity is encouraged!

All students/parents will need to complete the STUDENT REGISTRATION FORM to officially register for the conference.

# of Girls Registering from our School *
Your answer
# of Girls in need of Financial Assistance *
Your answer
Student 1
Your answer
Student 2
Your answer
Student 3
Your answer
Student 4
Your answer
Student 5
Your answer
Student 6
Your answer
Student 7
Your answer
Student 8
Your answer
Student 9
Your answer
Student 10
Your answer
Student 11
Your answer
Student 12
Your answer
Student 13
Your answer
Student 14
Your answer
Student 15
Your answer
Student 16
Your answer
Student 17
Your answer
Student 18
Your answer
Student 19
Your answer
Student 20
Your answer
Student 21
Your answer
Student 22
Your answer
Student 23
Your answer
Student 24
Your answer
Student 25
Your answer
Additional Information
If you have any additional questions or additional information regarding registration for your school, please indicate below, or contact me at sgreen@gwaea.org. Thank you!
Questions, Comments or Information:
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Grant Wood Area Education Agency. Report Abuse - Terms of Service