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Email *

Event Information

DATE: Friday, August 16, 2019

TIME: 12:00 pm - 2:00pm (Registration begins at 11:30 pm)

Location: Madison-Champaign ESC
2200 S US Highway 68
Urbana, OH, 43078

Credit: Contact Hours Provided by the ESC

Registration Fee:
$15.00

Payment Options:

Payment methods include cash, check, purchase order or credit card
(there is a 3% surcharge on all credit card payments)..

Payment can be mailed, emailed, or faxed to:

Mail to : Madison-Champaign ESC
Attn: Ashley Carey
2200 S. U.S. Highway 68
Urbana, OH 43078

Email: Ashley Carey at ashley.carey@mccesc.org

Fax: 937-652-2221

For Credit Card Payments: Contact Ashley Carey at ashley.carey@mccesc.org or call 937-484-1557
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Questions: Contact James Cutlip at james.cutlip@mccesc.org

Registrant's First Name *

Registrant's Last Name *

Registrant's Title / Position *

Registrant's Phone Number *

Please provide a phone number to be used in the event of a late cancellation.

Registrant's District / Organization *

Please list the organization responsible for paying the registration fee.

Please Select Payment Type *

Payment by Check

Payment by Purchase Order

Payment by Cash

Credit/Debit Card

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