Registration

Personal Information

First Name: *

Last Name: *

Name You Want On Nametag: *

Title:

Organization:

Address: *

Address 2:

Address 3:

City: *

State: *

Zip: *

Phone: *

Email: *

Additional Information

Emergency Contact:

Emergency Contact Phone Number:

Dietary Restictions:

Other Dietary Restrictions:

If you selected "Other" for Dietary Restictions, please explain here.

Special Needs:

Create WV will be held in various venues and multiple rooms. Please advise us of any physical conditions that might restrict your mobility or require special assistance.

Interests

Your Industy:

Track Interest:

Please indicate the track that you are MOST interested in attending. NOTE: This allows Create WV organizers to plan room space, but you are encouraged to attend sessions within any given track.

Bonus Activities - Please let us know if you plan on participating in these FREE additional activities::

StartUp 52 - A team will be available throughout the conference to help you activate your business idea! Take advantage of this networking opportunity with the team and other attendees. Bring your laptop and CREATIVE energy.

Vision Shared Volunteer Meeting – Tuesday, October 19, 2pm – 4:30pm. Interested in transforming West Virginia? Please join Vision Shared for a roundtable discussion regarding their 2010-2020 strategic plan. Your input is needed! For questions email info@visionshared.com.

Are you interested in car pooling?:

Yes

We will make every effort to connect you with attendees in your area prior to October 5, 2010. By checking this box you provide Create WV with permission to share your contact information with other attendees for this purpose.

Finish & Pay

Conference Attendance Options: *

Full Conference Attendee - $349: Your registration includes all conference sessions, including entrance to the welcome reception and related activities.

Artist and Student Attendee (Limited availability - Requires final approval) - $99: FULL-TIME students of any post-secondary educational institution such as a college, university or technical college. NOTE: Valid student ID must be shown during on-site registration at the conference.

Sunday Pre-Conference Workshop Only: I will not be able to attend the conference, but I want to register for one of the Pre-Conference Workshops (selected below).

I would like to attend one of the following pre-conference workshops
from 1pm – 4pm on Sunday afternoon, October 17, 2010. Please add $39
to my registration, which includes all workshop materials.

NOTE: The Sustainable Innovation Summit runs from 11am - 4pm.

Pre-Conference Workshops - $39 (choose one of the following):

Attracting Outside Resources for Our Appalachian Communities
Speaker: Mandy Hart - The Center for Appalachian Philanthropy. Connecting time, talent, and treasure can bring about positive change. Outside resources are needed to supplement our limited assets; and attracting them is easier if we collaborate.

Unlocking Creativity
Anyone and everyone can (and should!) be creative. Learn the secrets of unlocking new ways of thinking that can improve your community, company, school or non-profit.

Sustainable Innovation Summit 2010
Make innovation your business. Come together with entrepreneurs, executives and policymakers for learning, dialogue and debate on the central challenge of today’s economy – turning today’s ideas into tomorrow’s business breakthroughs.

Make a Contribution: $

I would like to make a tax deductible contribution to Vision Shared, Inc., a registered 501c3 non-profit corporation, towards Create WV activities. Please add the above amount on to my registration.

Payment Options: *

Online - Please register me to attend Create WV. I want to pay online with a credit card or PayPal account. NOTE: You will be sent to a PayPal payment page immediately after submitting this registration. Your registration is not complete until you have received confirmation from PayPal that your credit card has been accepted.

Refund Confirmation: *

I understand that I cannot receive a refund after October 1, 2010.

Create West Virginia

2010 Conference