LEAPE Train-the-Trainer Workshops Registration Form

1. Type information directly into this form.

2. Print the form. Sign and date it.

3. Mail the form along with a check payable to Cornell University for the registration fee ($45 for both days; $35 for second day only) to:

LEAPE Program Office, 307A Rice Hall, Cornell University,
Ithaca NY 14853

Name:
Position:
Organization

Mailing Address:

E-mail Address:
Telephone: Fax:

Training Location and Date

Indicate a first choice, and a second choice if you would be able to attend a different session

Owego (Tioga County)  first choice  second choice

Albany (Albany County)  first choice  second choice

Stony Point (Rockland County)  first choice  second choice

Ithaca (Tompkins County)  first choice  second choice

Will you attend first day session on GIS?  yes  no

Fee:

Attend second day only: $35.00

Attend both days: $45.00

Other information:

Will you attend the workshop with a local partner?
No Yes

Partner's Name & Organization:

Describe the first community in which you plan to deliver LEAPE:
Name of community:

Topic area of local issues:

marinas
turf
streamsides
roads
onsite wastewater
stormwater

Please describe local water supplies; land use patterns and density of development; nonpoint source issues; and/or work already being conducted on this issue (several sentences).

To what audience do you expect to introduce LEAPE? (e.g., Town Board, County Planning employees):

Miscellaneous

We will be providing lunch and other refreshments each day of the workshop. Please let us know of any special dietary needs and we will do our best to accommodate them.

How did you hear about the LEAPE Train-the-Trainer Workshops (check all that apply)?
email from Cornell to me
email from Cornell forwarded to me
print mailing from Cornell to me
print mailing from Cornell passed on to me
colleague mentioned it
presentation/other workshop
not sure
other (specify):

Signature_____________________________ Date __________________