Text Box: Shenandoah-Dives Workshop Registration

 

 Full name: __________________________________ ___________________________

           Last (Family) Name    First Name   Middle Name   Other Names Used

Mailing address:

Number and Street_______________________________________________________

 

Telephone ( _______ ) ______________________

 

City _________________State   _________ Zip ____________ County/Country __________________

 

E-mail _____________________________________________________________

 

 Person to be notified in case of an emergency _________________________________________

 

Relationship _______________________________

 

Address________________________________________________________________

 

Telephone ( ________ ) ___________________________

 

Text Box: Tell Us About You

 

 To assist us in tailoring the workshop to all participants’ needs and experience, please accompany your registration

request with the following information:

 

 Biographical Summary:  Arrange a chronological summary by year which lists your undergraduate and graduate

educational history, professional background, experiences and skills in preservation, volunteer work, major travel

experiences, creative achievements, and any other experiences which you believe may be of interest. Also list and

describe any preservation related publications or major research papers which you have written.

 

 Dietary Requirements: 

 

 Special Health Issues: (such as fear of heights, disabilities, allergies etc…)

 

Text Box: Registration Procedures

 Please submit all responses to this registration request, along with payment in full or a $50 (U.S.) nonrefundable

application fee to:

 

San Juan County Historical Society

Shenandoah-Dives Preservation Workshop

C/O  Beverly Rich, Chairperson or David Singer, Workshop Administrator

P.O. Box 295

Silverton, Colorado  81433  USA

 

Payment in full is required by July 15th, 2005 to insure your participation.

 

Those on our waiting list will be contacted to fill open spots after this date!

 

Form of Payment: Check or Money Order to San Juan County Historical Society

 

 

Silverton, Colorado

San Juan County

Historical Society