Training Entry Form

		National TOT Registration Form Print and complete the form below to register for the 2012 Michigan Model for Health^® Training of Trainers. The training is limited to twenty five participants. A few spaces remain available on first come first served basis. Please mail or fax this registration form to: Educational Materials Center (EMC) 139 Combined Services Building, CMU Mt. Pleasant, MI 48859 FAX: 989-774-3943
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____	I want to register for the August, 2012 Training of Trainers for Grades K-6 (Face-to-face training August 7-9. Plus advance work online)
____	Enclosed is my payment/purchase order for $___________. ($975* per participant)
____	I am a Michigan Trainer and have been in contact with my Regional Health Coordinator regarding this training and scholarship to attend.
____	Payment or a purchase order will be mailed. I understand that my registration is not confirmed until payment is received by the EMC.
	Name:__________________________________________ School/Organization: _______________________________ Address: ________________________________________ City/State/Zip: ____________________________________ Telephone: ( ) _________________________________ FAX: ( ) ______________________________________ e-mail address: ___________________________________ Telephone number during summer months: ( ) ____________________________ Special Diet requirements __________________________ (i.e. vegetarian, food allergies, etc.)

*Registration fee includes training, training materials, lunch and morning and afternoon breaks each day of training. Individuals are responsible for all other meals, lodging and travel.