Registration Form

Thursday, November 29 – Friday, November 30, 2007

Printable form for fax or mail.

REMINDER: Space and funding limitations require this to be an invitation-only event. Please do not register unless you have received an invitation. We hope to broadcast the Summit and will publish the proceedings as a document of record. Thank you.

Name and Company

(as you want it to appear on your name tag):

*First Name:

*Last Name:

*Title:

*Company/Org.:

Contact Information:

*Address:

*City: *St.: *Zip:

County I live in:

*Primary Contact #:

Work Phone:

Home Phone:

Cell Phone:

Fax:

*Email:

*Indicates required field

The Summit is an invitational two-day event with expenses paid by grants and donations. Our outcomes depend on your attendance for the two-day session. However, if scheduling conflicts prevent full attendance, please assist us by indicating the following: (See Summit Agenda for more information.)

Overnight Accommodations:

Space at the Samoset Resort is limited, RSVP, ASAP.

I will need a hotel room for Thursday, November 29.
Yes
No

I live more than 150 miles away and it is a hardship to arrive on time Thursday, so please provide a hotel room for Wednesday, November 28.
Yes
No

The Samoset is extending the $99.00 room rate to our participants for the weekend, November 30th & December 1st, at your own expense, please indicate here if you want accommodations:
November 30th
December 1st

Meal Attendance

In order to provide the Samoset with an adequate meal count and maximize our grant and donation revenue, please check for meal attendance:

Thursday, November 29th

Noon - Italian Pizza Party Buffet Lunch
Yes
No

5:30 PM - Reception
Yes
No

7:30 PM - Dinner (Please check one):
Sliced roast Sirloin with Mushrooms and Madeira Sauce
Herb Crusted Atlantic Salmon with Tomato and Caper Salsa
Marinated Portabella Mushroom with Stuffing (Spinach, Roasted Red Pepper, Havarti Cheese - Vegetarian Option)
Not Attending

Friday, November 30th

7:30AM - Buffet Breakfast
Yes
No

1:00PM - Luncheon (Please check one):
Skillet Seared Chicken atop Leek and Mushroom Stuffing with Dijon Pan Gravy
New England baked Haddock with herb crumb topping
Spinach Pesto Lasagna with Garlic Bread (Vegetarian Option)
Not Attending
Food allergies and/or Restrictions requiring specialized meals, please note here, and we will accommodate, if possible:

You may also print this form out and fax or mail it to:

Sheryl Peavey
Director, Early Childhood Initiative
Task Force on Early Childhood
Maine Department of Health and Human Services
State House Station #11
286 Water St, Key Plaza, 7th Floor
Augusta, ME 04333-0011

207.287.3339
207.287.5355 FAX

*Indicates Required Field

REMINDER: Space and funding limitations require this to be an invitation-only event. Please do not register unless you have received an invitation. We hope to broadcast the Summit and will publish the proceedings as a document of record. Thank you.