Registration

VIRGINIA IS FOR HEROES
October 17, 2007
Registration Form

REGISTRATION DEADLINE
October 10, 2007 (no walk-ins)

HOW TO REGISTER
Please print this page, complete the form, and mail with payment (or fax credit card payment) to:

Mid-Atlantic ATTC _________________Fax to Sally Holzgrefe: 804-828-4377
Virginia is for Heroes ________________Phone: 804/828-1014 /828-1014
700 E. Franklin St.
700 Centre, Suite 230
Richmond, VA 23298-0469

YOUR CONTACT INFORMATION

Name:_____________________________________________
Title:______________________________________________
Organization:________________________________________________________________________
Address:___________________________________________________________________________
City:___________________________________________State:_____Zip Code:___________________
Telephone#:______________________________________Fax:________________________________
Email Address:_______________________________________________________________________

WORKSHOP CHOICE (mark your top three choices with numbers 1, 2, + 3)

___ Child Advocates and Educators
___ Employers of Service Members
___ Veterans Service Organizations and other Non-Profits

___ Criminal Justice System
___ Faith-Based Leaders
___ Clinicians
___ Public Policy

CONTACT HOURS
___I want to earn six Contact Hours (recipients must attend entire conference) (CEUs not available)

SPECIAL DIETARY NEEDS
___ Check only if you require a vegetarian meal. A Continental breakfast and box lunch are provided.

PAYMENT INFORMATION
Registration fee $45.00

___ Check made payable to VCU Mid-Atlantic ATTC-Heroes
___ Credit Card

Type of card: Visa____ M/C ___ Discover ___ AMEX ___
Card Number ____________________________________________________ Exp. Date: ________

Name as it appears on the credit card: ____________________________________________________
(please print clearly)

Cardholder’s Signature: __________________________________________