REGISTRATION FORM

GEORGIA COUNCIL OF SUPERVISORS OF MATHEMATICS

ANNUAL WINTER CONFERENCE

JANUARY 31 - FEBRUARY 3, 2012

                                              Name ____________________________________________________________________

                                              Position _________________________________ Employee ________________________

                                              Email address _____________________________________________________________

                                              I will attend

                                                  Tuesday Night, January 31           yes ____     no ____

                                                  Wednesday, February 1               yes ____     no ____ 

                                                  Thursday, February 2                   yes ____     no ____

                                                  Friday, February 3                          yes ____     no ____

                                             I will attend all meal functions         yes ____     no ____

                                             If no please list the meals that you will NOT attend: ________________________________ 

                                            Do you intend to bring your spouse/guest.            yes ____     no _____

                                            List meals that your spouse/guest will attend.

                                            There is a one time $25 fee for spouse/guest who attend any meal function.

                                            Registration fee: $50.00

                                            Please mail in time for it to be received by the deadline.

                                            GCSM Tax number: 58-2008835

                                            Please mail this form with a check (no purchase orders or credit cards accepted) to:

                                            Margaret Faircloth

                                            1291 Triple Hill Drive

                                            Macon, Georgia 31206