Name:___________________________________________________________ Title:____________________________________________________________ SCHOOL/Business: _______________________________________________ Position: pFull Time pPart Time School Type: pPublic School pPrivate School Grade Level: pElem. pMiddle pSecondary pCollege Where would you like to receive MSLMA mailings? pSchool pHome Address for MSLMA Email:________________________________________ Please list the URL of your school website________________________________ SCHOOL Address: Street: ________________________________________________________ City: _________________________________________________________ State:_____ Zip: _______________ County:______________________ School Telephone:______________ School Fax:____________________ Library Region: pBoston pCentral pMetrowest pNortheast pSoutheast pWest HOME Address: Street _________________________________________________________ City:__________________________________________________________	§ Includes Membership from Nov. 1, 2004 to Oct. 31, 2005 § A check or school purchase order MUST accompany this form. Please make check payable to MSLMA. § Pre-registration ends October 8, 2004 – after that date, add $10 late fee § On-site registration must be accompanied by full payment § Refund Policy – Conference fees will be refunded due to illness if notification is made prior to the Conference. Meal costs cannot be refunded after 10/18/04. § Confirmation – Lists of confirmed registrants will be posted on the MSLMA listserv § MAIL this completed form to: MSLMA Administrator P.O. Box 505 Bedford, MA 01730-0505 Email: dsmith@mslma.org Tel/Fax: 781-275-0082 www.mslma.org
State:____ Zip: ____________ County:___________________________ Home Telephone:_______________________________________________ Are you a member of: AASL pYes pNo NEEMA pYes pNo Do you want to be listed by MSLMA as a Resource Person willing to share your expertise? pYes List Areas:___________________________________________________ MSLMA membership status (included in conference registration): pProfessional pRetired pLibrary Support Personnel pFull-time GSLIS student*	HSPECIAL RATE for MSLMA members! Join the New England Educational Media Association (NEEMA) for $20 (a savings of $10) Please send your check, made out to NEEMA, to: Carolyn Markuson, Member Chair 61 Hickory Sudbury, MA 01776 markuson@comcast.net Visit the NEEMA webpage: www.neema.org
*For membership purposes, a Full-time student is enrolled in a formal program and taking 3 classes. Please supply the name of the Master’s degree program in School Library Studies: ______________________________________________________________________ PLEASE TURN OVER AND COMPLETE CONFERENCE REGISTRATION INFORMATION ON THE REVERSE OF THIS FORM!	For MSLMA Office Use Only: School System: Check #___________________ School PO#________________ Amount:__________________

REGISTRATION Includes Membership, PLUS:

H Lunch

H Coffee

H Speakers

H Workshops

H Exhibits
HOn-line access to conference hand-outs!

EVENTS	MEMBERS	NON-MEMBERS	RETIRED/UNEMPLOYED/ FULL TIME STUDENTS*	FILL IN $ FEE
1 Day Conference	$100	$150	$85
Conference - Both Days	$150	$200	$135
Sunday Dinner CHOOSE ONE: Salmon p Turkey p Strict Vegetarian p	$25	$25	$25
Monday Lunch CHOOSE ONE: Buffet p *Box Lunch p
Note: Add $10 if postmarked after 10/8/04
TOTAL ENCLOSED
	School P.O. number, if applicable:

*For those who want to eat during a session