KMIC Mentor Training Pre-Registration

School districts can pre-register participants, by submitting a purchase order number acknowledging the member fee and the number of participants attending, with estimated amount. This Pre-Registration Form will be followed up with a contract and additional individual registration link information for participants.

All final registrations must be completed by August 15.

For questions, please contact KMIC Director, Deanna Gooch at (316) 833-1229 or deanna.gooch@wichita.edu.

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School District USD#*

District Contact Name*

District Contact Phone*

District Contact Email*

Street Address*

City*

Zip Code*

Registration Fees

$500 district membership (NOT $500 for all districts)
Annual District Membership Fee

1A, 2A, 3A = $250/year
4A, 5A, 6A = $500/year

$650 per mentor for online training

Note: districts sending more than 10 participants receive 10% discount

Total Number of Year 1 Online Participants @ $650 each

Total Number of Year 2 Online Participants @ $650 each

Total Number of Participants *

Estimated Total (include $500 district membership fee)*

Purchase Order Number*

Billing Contact Information

Billing Name*

Billing Address*

Billing City*

Billing Zip Code*

Billing Email Address*