Please check here if you would like vegetarian meals: YES ___ NO ___

Pleнase list below the code # and title of the workshop you would like to attend. List two alternatives (Example: T101,Technology Tools for Teachers) Please do not sign up for the same workshop you have previously taken, unless it is an advanced level.

FIRST CHOICE	Workshop #_____	Workshop Title_____________________________
SECOND CHOICE	Workshop #_____	Workshop Title_____________________________
THIRD CHOICE	Workshop #_____	Workshop Title_____________________________
# Graduate Credits:	Viterbo University _____	Edgewood College _____

_____I would like to participate in the ide@s Research Schнolar Option

* You may have additional credit/pay options through your School District, contact your District for details.

I have previously attended the John Muir Academy (please check the following) YES ___ NO ___

John Muir Academy tuition fee: $375.00 (includes a nonrefundable $50.00 fee.)
Registrations received after June 18, 2010, will be $400.00. Registrations received seven days before the Academy OR on the first day of the Academy will be $425.00. No refunds will be given for cancellations the week before the Academy or for "no shows."
Fees include workshop, tours, continental breakfasts, breaks and lunches.

Applicant: Please make Registration checks payable to the John Muir Academy.Please complete this form and FAX to us at (608) 223-2445н, and then mail with payment to John Muir Academy at P.O. Box 259412, Madison, WI 53725-9412.
A Confirmation Packet will be sent two weeks before the start date of the Academy.

Payment for graduate credits should be paid directly to Viterbo University or Edgewood College on the first day of the Academy.

Check to receive registration materials from: Viterbo University ___ or Edgewood College ___

To be completed by John Muir Academy

Date Appl. Received:	Faxed __________	Mailed __________
Method of payment:	Check Enclosed -	Amount Rec. ______	Check # ________
н	P.O. # __________	Billed Date ________	Date Rec. ________	Amount Rec. ________

BACK TO HOME PAGEн н

ннNAнME: _____________________________н	SCHOOL DISTRICT: ____н_______________________
HOME ADDRESS: н_______________________________	SCHOOL NAME:нн ___________________________
CITY - STATE - ZIP: _______________________________	GRADE LEVEL:___________________________
PHONE:_______________________	DISCIPLINE TAUGHT: ___________________________
EMAIL: ____________________________	SCHOOL PHONE: ___________________________
CIRCLE ONE: Public School or Private School