Grassroots Indian Nation Tour Registration Form

Name ______________________________________________


City _______________________________ State__________Zip_____________

Phone (______)___________________

Email _______________________________________________

The University of Wyoming is committed to making this conference accessible to all individuals. If you have special needs and require accommodations to participate in this activity, please let us know. You will be contacted by someone from the Special Programs Office to discuss your specific needs. ** Participants must be physically able to board & exit tour vans frequently.

Registration Fees:
Student $ 1,000 $ __________
3 Credit Hours Tuition
     Undergraduate $262.50 $ __________
     Graduate $433.50 $ __________
Non-Student (inclusive fee) $1,500 $ __________
Deposit $250 $ __________
required immediately to ensure participation & deducted from final balance
Total Amount Enclosed $ __________

Make checks payable to UW/Grassroots Tour. Mail payment and registration form to:

     Special Programs/Grassroots Tour
     P.O. Box 3972
     Laramie, WY 82071-3972

To register by Phone (1-877-733-3618. ext. 3; 307-766-5634) or FAX (307) 766-3914, you must use a VISA/MasterCard, or AMEX card.

Card # __________________________

Exp. Date ________________________

Cancellation/Refund Policy: Written cancellations received before 6/15/01 will receive a full refund subject to a $35 processing fee. No refunds for no shows.