THE BACCHUS NETWORK- AREA 6 CONFERENCE
University of Central Oklahoma
FEBRUARY 22-23, 2007
Please type or print legibly:
School Name
Advisor (s) Name
Daytime Phone ( ) Fax Number ( )
Mailing Address
City, State, Zip
Names of Attendees, Status (i.e. Student, Advisor, and other) and shirt size (S, M, L, XL, XXL):
Attendees’ Names Status Leadership/ CPE T-Shirt Size
1. ______________________ _________________ ________________ ___________
2. ______________________ _________________ ________________ ___________
3. ______________________ _________________ ________________ ___________
4. ______________________ _________________ ________________ ___________
5. ______________________ _________________ ________________ ___________
6. ______________________ _________________ ________________ ___________
** If you need additional space, attach a copy or an additional list of all names to this document. **
Number of Attendees X $ 60.00 =
CPE Training X $ 25.00 =
Leadership Pre-Conference ____________________ X $15.00= __________________
Late Fee (Per Student) after Feb. 4, 2007__________ X $5.00 =
Total Due
Payment Type: 
Check Enclosed: (Make all checks payable to The Bacchus Network)
Credit Card: (Complete Information Below)
Name on Card ________________________ Type ____________________________
Number _____________________________ Expiration Date _____________________
Signature ____________________________
Please submit registration forms to:
Kimberly Harvey-Livingston
3900 University Blvd; Tyler, Tx 75799
Phone# (903)566-7197; Fax # (903)566-7242
e-mail: Kim_Harvey-Livingston@mail.uttyl.edu
** This year, we will hold 2 pre-conference sessions.
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Certified Peer Educator Training &
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Leadership and Diversity in Peer Education.
Watch for more information coming soon!!