2014 SCPITC Advanced Training Out-of-State Residents Registration Form South Carolina PITC Advanced Training March 3 and 4, 2014 Registration begins Monday at 10:30 a.m. The final meeting ends Tuesday at noon. Once you have submitted your online enrollment form, please send your payment prior to February 7, 2014. We will accept checks and purchase orders. Make check or purchase order payable to the University of South Carolina. Mail your payment, to: South Carolina PITC Advanced Training USC Child Development Research Center 1530 Wheat Street, Ste. 220A Columbia, SC 29201 Our Federal Tax I.D. number is 57-6001153 Please be sure to include your contact information with your payment. We hope to accept all who apply, but if the number of registrations exceeds our capacity, South Carolina registrations will have priority over out-of-state registrations and applicants who have achieved PITC certification will have priority over those who are not certified. Please contact Janelle Beamer if you have any questions: BEAMERJ@mailbox.sc.edu (preferred) or 803-777-2109.Date *Personal InformationFirst Name *Middle Initial Last Name *Nickname for Nametag Job Title *Enter Your Email Below *Direct Phone (000) 111-1111Mobile Phone (000) 111-1111Fax (000) 111-1111Home Address Please note that this will be used as your mailing address.Street Address *Address Line 2 City *State *Zip Code *County *Home Phone (000) 111-1111Home Fax (000) 111-1111Organization Information Your name and organization information will be included in the participant list, which will be distributed to the attendees at the conference.Employer Name *Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryCounty *Web Site Address Main Phone (000) 111-1111Extension Main Fax (000) 111-1111Advance Training Registration Fee Out-of-State Residents: $225 Registration Fee (includes double occupancy room, meals and conference materials but does not include hotel parking.)Hotel Accommodations Please note that the Conference Coordinator will reserve all hotel rooms. You should not contact the hotel directly for reservations.Your Preferred Hotel Occupancy Accommodations *Please Select the Appropriate Radio Button Below for Your Preferred Hotel Occupancy AccommodationsDouble Occupancy - You will choose your roommate preferences belowSingle Occupancy - A very limited number of single rooms are available on a first-come, first serve basis. Every effort will be made to accommodate single room requests. If a single room is not available you will be notified and the additional fee will be reimbursed to you. If a single room is available you will pay the single room fee of $165 plus the $140 registration fee for a total of $305. If you are requesting a single room in the conference hotel and one is not available then you will make arrangements for your own accommodations.No Hotel Accommodations Needed - All participants must pay the registration fee: $140.Roommate Request for Double Occupancy Please Complete the Section Below if You Have Chosen Double OccupancyI am requesting to room with a particular individual (to be input below)I do not have a particular roommate requestI am requesting to room with the following individual: The above field will be left blank if you are requesting single occupancy, do not require hotel accommodations, or do not have a particular roommate request.No Particular Roommate Request If you do not have a particular roommate request, please choose the options below that apply to you.I am a femaleI am early to bedI snoreI am a maleI am a night owlI smokeAdditional Information Please let us know if you require any of the below:I require a wheelchair-accessible room.I have special dietary needs (preferences to be included below)Special Dietary Needs Please indicate special dietary needs below.Other Accommodations Needed Please list any other accommodations that are necessary to enable you to participate fully in the conference:Understanding of All Policies Cancellation Policy: We cannot offer refunds, but substitutions will be accepted.Confirmation of Cancellation Policy and All Other Policies *Please select the radio button below if you have read and understand the cancellation policy and all other policies stated in this application.I have read and understand the cancellation policy and all other policies stated in this application. Click the Submit Button BelowPlease Enter Your Age BelowThis section is required to control computer spoofing and to verify that you are a person. Your age must be entered in two digits with no spaces (Example: 38). If you choose, you are not required to enter your real age but you must enter a two digit number with no spaces.This box is for spam protection - please leave it blank: This event is sponsored by the SC Program for Infant/Toddler Care and coordinated in partnership with the USC Yvonne & Schuyler Moore Child Development Research Center, and the ABC Child Care Program.