REGISTRATION FORM

Cycles of Success

(Please type or print clearly)

SCHOOL DISTRICT __________________________________________

Name of Superintendent ____________________________________

Address: _________________________________________

City/State/Zip Code: _______________________________________

Phone ( ) ______________ FAX ( ) _________________

Contact E-Mail ____________________________________________

Costs:
Per year (12 sessions) - $950 (free make-ups in the following year)
Per Session - $95
This workshop is BOCES aidable through COSERs 504 and 512 -
cross-contract with the Steuben-Allegany BOCES.

TOTAL AMOUNT: $ ________

COHORT LOCATION: ______________________________

Check one METHOD OF PAYMENT:

____ Check or purchase order enclosed # _______________
to "Steuben-Allegany BOCES" (not needed if cross contracting).

____ Please bill through my BOCES on cross-contract with the
Steuben-Allegany BOCES, COSERs 504 and 512 as follows:

Name of BOCES _______________________________________
NOTE: School districts who are not components of the Steuben- Allegany
BOCES must request a cross-contract for Coordination COSERs 504 and 512.

Superintendent's
Signature: ___________________________ Date: ___________

The registration fee includes program materials each session day.

FAX to: (716) 672-5472 then mail original to:
Dr. James M. Merrins, Executive Program Administrator;
Steuben-Allegany BOCES, Superintendent Support Programs
42 Rosalyn Court, Fredonia, NY 14063

QUESTIONS: State Office (716) 672-5473