KET Staff Services

Tuesday, July 14
Wednesday, July 15

Name:

School:

District:

County:

Address:

City:

State:

Zip Code:

Job Title:

Phone:

E-Mail:

If you are not currently a member of KET’s MediaWorks e-mail listserv for school video-multimedia information sharing, may we add your e-mail address to the list?

Yes
No

If you will not be checking your school mail or e-mail during the summer break, please provide an optional address where we may contact you:

Address:

City:

State:

Zip Code:

E-Mail:

Phone:

Method of payment (check one):

Check
School Purchase Order
Credit Card (Visa or MasterCard only, please)

If paying by credit card:

Name as it appears on card:

Billing Address

City

State

Zip

Card number (no spaces or dashes, please):

Expiration date (mmyy):

I give KET permission to use video or audio recorded by KET during the KET Multimedia Professional Development Days 2009 in any later KET-produced video, audio, or Internet projects, including web pages and Internet video streaming.

_______________________________________
Signature of participant

_______________________________________
Date

________________________________________
Printed Name

________________________________________
Title