registration form

TEACHER/ADULT ADVISOR
PROFESSIONAL DEVELOPMENT OPPORTUNITY
NOBEL PEACE LAUREATES MENTORING YOUTH TO CHANGE THE WORLD
The PeaceJam Foundation is excited to offer training sessions on our unique and powerful
service-learning curricular programs that connect youth ages 5-18 to the lives and work of 13
Nobel Peace Laureates who are personally involved with PeaceJam. PeaceJam programs
are designed for in-school, after school, faith-based, and community-based program use.
ANTI-BULLYING CURRICULUM TRAINING
For teachers/adult advisors working with
middle and high school aged youth
SATURDAY, May 16th, 2015
9 a.m. to 3 p.m.
University of Connecticut, Storrs, CT
New Adult Advisors: $250 for 2 people from the same organization
2015 PeaceJam Conference participants: $50/each
(to cover curriculum printing and food costs)
How would the Dalai Lama and Desmond Tutu handle bullying? Explore how Nobel Peace
Laureates approach the issue with a program that incorporates diverse global, ethnic, and
cultural perspectives!
Get trained to implement Compassion in Action: Multicultural Approach to Bullying Prevention in
your school, youth organization, and community. The curriculum explores bullying as
interpersonal, social, and institutional oppression, gives students the tools to address the root
causes of these injustices, and draws from the experience of Nobel Peace Laureates.
SPACE IS LIMITED! PRE-REGISTRATION REQUIRED
PLEASE SEND COMPLETED REGISTRATION FORMS AND FEES TO:
Kate Cumbo• 11200 Ralston Road • Arvada, CO 80004 • Phone: 303-455-2099
[email protected]
Make checks payable to the PeaceJam Foundation
TEACHER/ADULT ADVISOR
TRAINING REGISTRATION FORM
You may bring up to two people from your organization/school for one registration fee. Those being trained for the first time are
required to pay an initial training fee of $250. Those who are returning PeaceJam Adult Advisors/Teachers may pay the renewal
fee of $100. If one person is a returning Adult Advisor/teacher, but the second person is being trained for the first time, the initial
training fee applies. Both participants must attend the training in the same program and must attend training on the same day.
The registration fee includes meals for each participant, one curriculum, one set of videos, online resources, and training. This fee
is per organization and may not be shared between organizations. No refunds are granted for cancellation by participants or for
absences. No partial fees will be granted for only one participant.
School or Organization: ____________________________________________________
Participant 1: ____________________________________________________________
Address: _______________________________________________________________
City: _____________________________ State: ____________________ Zip: _________
Email: _________________________________ Phone: __________________________
Dietary restrictions, physical accommodations, or other needs:
NOTE: some dietary restrictions may not be able to be accommodated—please make a note if you require a vegetarian lunch.
_______________________________________________________________________
Participant 2: ____________________________________________________________
Address: _______________________________________________________________
City: _____________________________ State: ____________________ Zip: _________
Email: _________________________________ Phone: __________________________
Dietary restrictions, physical accommodations, or other needs:
NOTE: some dietary restrictions may not be able to be accommodated—please make a note if you require a vegetarian lunch.
______________________________________________________________
REGISTRATION FEE PAYMENT INFORMATION:
Please select your registration type and method of payment. No participants are confirmed until payment is received.
I am/we are NEW to PeaceJam and will pay the $250 initial training fee.
I am/we attended the NEW ENGLAND PEACEJAM CONFERENCE and will pay the $50
discounted fee per person.
PAYMENT TYPE:
I will pay by CHECK: Make payable to the PeaceJam Foundation and bring to training
I will pay by PURCHASE ORDER: Send to the address below
I will pay by CREDIT CARD: Call the phone number below for payment instructions
PeaceJam Foundation
11200 Ralston Road • Arvada, Colorado 80004 Phone: 303-455-2099
[email protected]