VERA Conference Registration Form:

Name:______________________________________________________

Affiliation:__________________________________________________

Mailing Address:_____________________________________________

City/State/Zip:_______________________________________________

Work Telephone:_______________________

Fax:__________________________________

Email:________________________________

Registration Information (check applicable status)

STATUS                                                                       AMOUNT

________ Current Member                               ________

________ Student                                                ________

________ Luncheon                                        ________

Luncheon Choice                                                         

Vegetarian _____ Chicken_____

________Membership Only ($40.00)                         ________

________ 1-Day Attendance                                 ________

________ Registration after March 15                  ________

($115.00 – Students $70.00)

________ Program Evaluation (Pre-session)           ________

(Must register, prior to March 15)

Total Amount Included                                                   ________

Mail Form and Fees to:

Ruth Grimes-Crump
1403 Idlewood Avenue
Richmond, VA 23220