PLEASE PRINT THIS PAGE, FILL OUT, AND RETURN TO THE KAGE OFFICE.

Applicant's Name_________________________________________________________

Street Address__________________________________________________________

City, State, Zip____________________________________________________________________

Home Phone #_______________________ Work Phone #______________________________

Email Address__________________________________________________________

A specific number of parents will be designated from each federal congressional district. If a district does not fill its quota, then parents from other areas will fill the places.
Please circle the federal congressional district that applies to your area.

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Are you a current KAGE member? YES____ NO*_____

Please remember that:
- Lunch will not be included.
- *If you are not a KAGE member, there will be a $30 additional fee to become a member.

I verify that I am not a certified employee of any educational system.

_____________________________________
Signature

_____________________________
Date

The application and check for the remaining amount of the registration fee must be included with the registration form. You will be notified of your acceptance.

Please send registration form to:
KAGE, PO Box 9610, Bowling Green, KY 42102-9610
For more information contact the KAGE office at kage@wku.edu, 270.745.4301, fax: 270.745.6279 * www.wku.edu/kage