SOUTH CAROLINA COMMUNITY ACTION PARTNERSHIP &

SOUTH CAROLINA STATE HEAD START ASSOCIATION

2017 STATEWIDE MID-FALL TRAINING CONFERENCE

NOVEMBER 6, 2017 – NOVEMBER 9, 2017

Embassy Suites Myrtle Beach Oceanfront, 9800 Queensway Blvd., Myrtle Beach, SC 29572
Direct Line: 843-449-0006| Fax: 843-497-1017

R E G I S T R A TI O N F O R M

Agency Name / Agency Contact:
Address:
Email: Fax: / Phone # ( )

■SC State Head Start Association Member Agency? (SCSHSA)? Yes___ No_____ Members qualify for the member rate.

■SC Community Action Partnership Member Agency? (SCCAP)? Yes____ No______Members qualify for the member rate.

■SC CAP Directors Association Member Agency? (SCCAPDA)? Yes ____ No____ Members qualify for the member rate.

****AGENCY AND PARTICIPANT MUST BE MEMBERS TO QUALIFY FOR THE MEMBER RATE****

(Agencies will be billed the non-member rate if non-members are registered at the member rate)

PLEASE TYPE OF PRINT NAMES TO APPEAR ON NAME TAGS “LEGIBLY PLEASE”

# / Last Name / First Name / Position/Title / Are you a Member?
(Y/N) / Registration Fee / CAA / HS / Other / DAILY
DATE
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2
3
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9
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Please check the boxes that apply:

MEMBER / NON-MEMBER
 Early Registration: / $375.00 / $450.00 / Received by
September 22, 2017
 Regular Registration: / $395.00 / $475.00 / Received By
October 16, 2017
 Onsite Registration: / $434.00 / $525.00 / Received After
October 20, 2017
 Daily fee: ( includes training, materials and amenities for the day attending) / $175.00 / $250.00 / LIST ATTENDANCE DATE:
Check Amount: / Check Number(s)
Total Participants: / Page: / of / Purchase Order Number(s):

Payment must accompany registration form. Registration fees are non-refundable. However, fees are transferable to another conference participant. Remit certified check, money order, agency check, personal check, or purchase order PAYABLE TO: SOUTH CAROLINA ASSOCIATION OF COMMUNITY ACTION PARTNERSHIPS, INC

ATTN: Registration, 2700 Middleburg Drive, Suite 213, Columbia, SC 29204 by OCTOBER 16, 2017.

Telephone: (803) 771-9404, Fax: (803) 771-9619, Email: , Website: www.scacap.org

Submit this entire document.

08-18-2017