Minnesota Council of Teachers of Mathematics
2012 Spring Conference Registration Form
Register prior to April 13, 2012 and receive the early registration discount rate.
Advance registration closes Friday, April 27, 2012. After this date you may register on-site.

You may also print and mail to MCTM, PO Box 289, Wayzata, MN 55391.
If you have any questions, please contact Tom Muchlinski by email at tmuchlinski@earthlink.net.
Name:
Address:
City / State / Zip:
Email:
If you are a new member, or if any of the following has changed, fill in the information below
Home Phone: Work Phone:
District Name: School / Institution:
Level Position
Elementary
Junior High/Middle
High School
District
Post Secondary
Other

Undergraduate Students ONLY - Please indicate your level of certification:
K-8 5-12 		Teacher/Professor/Instructor
Specialist/Coach/Supervisor
Administrator
Undergraduate Student
Retired
Other

SPRING CONFERENCE REGISTRATION FEES

- Friday and Saturday registration fee includes two lunches and the Friday afternoon President's Reception
- Saturday only registration fee includes one lunch
- Non-member and lead speaker registration fees include a one year MCTM membership fee
- There is no Friday only registration

CANCELLATION POLICY

For refund requests received by Friday, April 27, 2012, MCTM will refund 50% of your registration fee.
After this date, no refunds will be given.

ON-SITE REGISTRATIONS OR THOSE POSTMARKED OR SENT AFTER APRIL 13, 2012 WILL NOT QUALIFY FOR THE EARLY REGISTRATION DISCOUNT RATE
Friday and SaturdaySaturday Only
MCTM Member $165.00 ($180.00 after 4/8/11) $110.00
Non-Member $190.00 ($205.00 after 4/13/11) $135.00
Student Member $85.00 ($100.00 after 4/13/11) $65.00
Student Non-Member $97.50 ($112.50 after 4/13/11) $77.50
Lead Speaker$60.00 ($75.00 after 4/13/11) $40.00
Vegetarian Meal Requested
Gluten Free Meal Requested
MCTM Dues
New   Renewal   Do not need to renew
Regular Membership Student / Retired Membership
One Year - $25.00   Two Year - $40.00 One Year - $12.50   Two Year - $20.00
I would like to make a tax-deductible contribution of $ to the MCTM Foundation
Conference attendees should arrange their own lodging. For information about conference lodging in Duluth see www.mctm.org or call 1-800-438-5884 or visit www.visitduluth.com
Amount Due Method of Payment
Registration Fee
MCTM Dues
Fall Conference Discount
Foundation Contribution (Optional)
Total Due		 Credit Card
PLEASE NOTE: You will be prompted to pay via PayPal after this form has been submitted.
The PayPal form will say "donation", but it IS your conference fee payment)

Check payable to MCTM
PO Number
If using a P.O., please send a copy either via surface mail
or as an email attachment to tmuchlinski@earthlink.net. Mail checks and P.O.s to:
MCTM
PO Box 289
Wayzata, MN 55391