Last Name: _______________________ First Name: __________________ (Title:) _________

Preferred mailing address: Home_______ School_______

Home Address: (include city, state, and zip)
____________________________________________________________________________

Home Phone #: _______________________ County in which you teach: ___________________

Preferred E-mail Address: ____________________________________________________________________________

School/College Name: _________________________________________________________________

School/College Address: (include city, state, and zip) ____________________________________________________________________________

School Phone #: ____________________________ School Fax #:________________________

Level(s) you teach or supervise - circle all that apply: K, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, C

Professional organizations to which you belong: AMTNYS___ NCTM ___ NYSAMS___ Other
____________________________________________________________________________

If you are in your last year of college, please leave an address to which mail can be sent in 2010:
____________________________________________________________________________

Registration fee includes $5 Membership, breakfast, 4 workshops, and lunch

Pre-Registration:	On-Site Registration:	Mail Registration and Check payable to:
—Teacher $35	—Teacher $45	Treasurer, TCMEA
—Student $20	—Student $45	c/o Suzanne Libfeld
Membership Only $5		2843 Old Yorktown Road
		Yorktown Heights, New York 10598