Registration Form - Step 1

Printable version of this form

Registration form for Friday, November 4, 2011 Tutor/Mentor Leadership & Networking Conference. Registration is completed in three steps:

Step 1 - Registration: Complete and Submit the registration form separately for each person attending the conference.

Step 2 - Payment: Select and Pay for one or more registrations.

Step 3 - Confirmation: Check your email for your email confirmation letter.

If you have any questions during this process, please contact us at tutormentor2@earthlink.net.

Complete and submit the registration form separately for each person attending the conference.

Contact Information

*First Name:
*Last Name:
Title:
Program/Department:
Organization/Company:
Address:
City:
State:
Zip:
Phone:
Fax:
Website:
*Email:

*Your email address will be used to confirm your registration.  You will also be added to a mailing list for important Conference announcements and information. You can unsubscribe from this list at any time.  We will not share, sell, or spam your email address.

Lunch Options

 Please check this box to request a vegetarian lunch.

Online Attendee List

We maintain an online list of people attending our conference. This list is intended to help attendees connect with other attendees. With your permission, we will publicize your full name, organization, city and state only. People will be able to contact you via a form but your email address will not be revealed.

Yes, please add me to the online list of attendees for this conference.


This is a one-day conference.

Friday, Nov. 4 - full day $80; half day no fee

How will you pay for this registration?

Online via PayPal

By Mail (check) Use address below.

At the Door (cash or check only)

Click here to request $20 scholarship rate.

Payment & Mailing Address

Make checks payable and mail to: Tutor/Mentor Connection, Tutor/Mentor Institute, LLC., Merchandise Mart PO Box 3303, Chicago, Il. 60654.



Questions or Comments (if requesting a scholarship, write in the comment box that you agree to the $20 scholarship rate. If registering for half day there is no fee. Just write that you will be attending half day in comments box):

When you click Send, your form will be sent immediately.  Please double check your information before you click Send.