Please check here if you would like vegetarian meals: ___

Please list below the code # and title of the workshop you would like to attend. List two alternatives (Example: T101, The SMART Class) Please do not sign up for the same workshop you have previously taken, unless it is an advanced level.

FIRST CHOICE	Workshop #_______	Workshop Title_____________________________
SECOND CHOICE	Workshop #_______	Workshop Title_____________________________
THIRD CHOICE	Workshop #_______	Workshop Title_____________________________
# Graduate Credits:	Viterbo University _____

_____I would like to participate in the Ide@s Research Scholar Option (please see the Ide@s application link on our homepage)

* You may have additional credit/pay options through your School District, contact your District for details.

I have previously attended the John Muir Academy (please check the following) :
YES ____, year(s)___________ NO ___

John Muir Academy tuition fee: $375.00 (includes a nonrefundable $50.00 fee.)
Registrations received after June 15, 2012, will be $400.00.
Registrations received seven days before the Academy OR on the first day of the Academy will be $425.00.
No refunds will be given for cancellations the week before the Academy or for "no shows."
Fees include workshop, tours, continental breakfasts, breaks and lunches.

____ I would like to participate in the payment plan, and have enclosed my first payment of $100.00. (Initial registration must be received before June 15, 2012).

Applicant:
Please make registration checks payable to the John Muir Academy.

Please complete this form and mail with payment to:
John Muir Academy
P.O. Box 259412
Madison, WI 53725-9412.

A Confirmation Packet will be sent two weeks before the start date of the Academy.

Payment for graduate credits should be paid directly to Viterbo University on the first day of the Academy.

Check to receive registration materials from Viterbo University ___

To be completed by John Muir Academy

Date Appl. Received:	Mailed __________	E-mailed __________
Method of payment:	Check Enclosed ___	Amount Rec. ___________	Check # ____________	PO # ____________
	Billed Date __________	Date Rec. ___________	Amount Rec. ____________	Check # ____________	PO# ___________
Payment Plan:	Date Rec. __________	1st Payment: Date:_________ Amt:_________ Chk#:________ PO#:_________	2nd Payment: Date:_________ Amt:__________ Chk#:_________ PO#:__________	3rd Payment: Date:__________ Amt:__________ Chk#:_________ PO#:__________

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NAME: _____________________________	SCHOOL DISTRICT: ___________________________
HOME ADDRESS: _______________________________	SCHOOL NAME: ___________________________
CITY - STATE - ZIP: _______________________________	GRADE LEVEL: ___________________________
PHONE: _______________________	DISCIPLINE TAUGHT: ___________________________
EMAIL: ____________________________	SCHOOL PHONE: ___________________________
CIRCLE ONE: Public School or Private School