2023 BRILLA Summer Institute Registration Form

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June 12-15, 2023

CSU, Chico Colusa Hall 100, 9:00 a.m. to 3:00 p.m.

(Catered breakfast and lunch provided.)

First Name *

Last Name *

Email *

(Please provide an email address you regularly use.)

Phone number *

Last 4 of Social Sec # (We need this to process payment for the institute stipend.) *

If you don't have a Social Security number, please enter "n/a"

Chico State ID# (if student)

Street Address *

(Local mailing address)

City *

State *

Zip *

If you are fluent in any language other than English, please list the language(s) below.

T-Shirt Size for the 2023 BRILLA Summer Institute *

(Please select style/size.)

Women's Small

Women's Medium

Women's Large

Women's XLarge

Men's Medium

Men's Large

Men's XLarge

Men's XXLarge

T-Shirt Color for the 2023 BRILLA Summer Institute *

(Please select color.)

Black

White

Please select your registration type below. *

In-Service Teacher TWI Classroom

In-Service General Education Classroom

Pre-Service Student Multiple Subject

Pre-Service Student Single Subject

Paraprofessional

Special Assignment

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