PUT THE 2012 MIDSTATE CONFERENCE ON YOUR CALENDAR TODAY!

MARCH 9, 2012
EASTERN ILLINOIS STATE UNIVERSITY, CHARLESTON

SOMETHING FOR EVERYONE!
ELEMENTARY, MIDDLE, AND HIGH SCHOOL SESSIONS

In-depth Session Descriptions will be available on the IAHPERD web site after January 12, 2012.

Pre-registration Cost
• Members: $60.00 (includes lunch and conference materials)
• Non-members: $110.00 (also includes membership to IAHPERD)

Register by March 1, 2012

Personal Information

Membership Status

Member

Non-Member

Salutation

First Name

Last Name

Mailing Address

City

State

Zip

numbers only

Home Phone

numbers only

Work Phone

numbers only

Home County

Work County

Email Address

School Name

City

State

Zip

numbers only

Total

Payment
Credit Card Type
Credit Card Number	numbers only
Security Code	numbers only
Expiration Date	(mm/yy)
Name On Card
	Same as Mailing Address ?
Billing Address
Billing Zip

IAHPERD DOES NOT ACCEPT PURCHASE ORDERS !!!!!!

PUT THE 2012 MIDSTATE CONFERENCE ON YOUR CALENDAR TODAY!

Register by March 1, 2012

Personal Information

Payment