Health Education Summer Conference 2022

• Date: Monday, June 27 & Tuesday, June 28, 2022
• Time: 9:00 a.m. to 3:00 p.m.
• Site: CAS-CIAC, 30 Realty Drive, Cheshire, CT 06410
• Registration Deadline: Friday, June 24, 2022
• Cost: $125.00

Note: Items with * are required.
Registrant Name*:	First*: Last*:
Affiliation*: Choose a High School... Choose a Middle School... Choose a Elementary School... Choose a District Name... Other (not included in the options above)
Phone*:
Fax:
E-Mail*:
Re-Enter E-Mail*:
Mailing Address*:
City, State and Zip*:	CT AL AK AR AZ CA CO CT DE DC FL GA HI ID IA IL IN KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Payment Method*:	VISAMasterCardPurchase OrderSend Check
Credit Card/P.O. Number*:
Expiration Date*:	1 2 3 4 5 6 7 8 9 10 11 12 /20
Name on Card*:
Card Verification Code*: [Where do I find this?]
Billing Address*:
Billing City, State and Zip*:	CT AL AK AR AZ CA CO CT DE DC FL GA HI ID IA IL IN KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Note: Credit card number, expiration date, name on card and billing address fields are required only if you choose VISA or MasterCard as your payment option
Grade Level	ElementaryMiddleHigh SchoolDistrictOther