PARTICIPANT INFORMATION FORM

Margaret Sue Copenhaver Institute, June 23-25, 2014

PLEASE RETURN BY APRIL 14.

(If you must decline the invitation, please inform us as soon as possible).

Your Name: Rev. Dr. Mr. Ms. Mrs.

Title/Position (Include grade level)

Home Address

Street AddressCity, State, Zip

School Info

School NameSchool District(e.g., Brown County Schools)

School Address

School Phone Home Phone

E-mail Address

●Are you either an active or inactive member ofKDP International Education Honor Society? Yes No

●Are you a Roanoke College student or alum? Yes No

● Have you supervised a Roanoke College preservice teacher in the last three years? Yes No

Please check as applicable:

 I accept my position as participant in the Copenhaver Institute.

 I cannot accept my position as participant in the Copenhaver Institute.

Lodging:

Campus lodging is optional. If you choose to stay on campus, a complimentary room in a residence dormitory hall will be provided for Monday evening, June 23,and Tuesday evening, June 24. NOTE:

With exceptions for married couples, all rooms are single. Rooms are air-conditioned, clean and offer basic furnishings. Residents on each floor share a bathroom and shower facility. If desired, you may elect, instead, to make reservations at an area inn. All off-campus arrangements must be made by the participant. Please see the MSCI Web site( click on the“This Year’s Program” tab, “Lodging,” to view a list of off-campus facilities.If campus lodging is requested, please note that a $20 room key deposit (in form of cash or check) is required upon check-in and will be returned at checkout.

 I do not choose to stay on campus.

 I choose to stay on campus. I need accommodations for:

Single room–Female Single room–Male

 Married Couple (please indicate spouse name)

Early Arrivals:

Those traveling significant distances to attend the Institute may request lodging on the Roanoke College campus for Sunday evening, June 22. There is a $40charge for this. If you would like to request this option, please designate below and also include an additional $40 with your registration fee.

 I would like to reserve a room for Sunday evening, June 22.

Fitness Opportunities:

 Please sign me up for a Tuesday afternoon walk through Salem’s scenic Greenway River Walkway.

 Please sign me up for an early morning fitness walk on Tuesday.

 Please sign me up for an early morning fitness walk on Wednesday.

Special Needs:

We want to make sure that while you are at the Copenhaver Institute, you have your physical needs met. Please indicate below any special needs that you have:

 I would prefer to order a vegetarian meal for the Institute luncheon on June25.

 I will need lodging that is wheelchair-accessible.

If there are other requests you would like to make, please indicate:

Directory:

Do we have your permission to include your name, e-mail address, school and division in a directory that will be provided to fellow participants? The directory will not be provided to any organization or individual other than MSCI participants. It serves as a means for participants to keep in touch with one another following the Institute.

 Yes, I would like to be included in the participant directory.

 No, I would prefer not to be included in the participant directory.

Workshop Designation:

In order to provide relevant workshops, we hope to offer breakout sessions designated by grade level taught. Please designate your preference for these sessions.

 PRIMARY GRADES (K-2)educator

 UPPER ELEMENTARY GRADES (3-5)educator

 MIDDLESCHOOL (6-8)educator

 HIGH SCHOOL (9-12) educator

 ADMINISTRATOR (Title: )