Sharing Our Stories:  The Second Wave Feminist Movement
Registration Form
Friday, March 31
Hilton Durham (near Duke University), Durham, NC



Name: First_____________________________ Last_____________________________

Email address____________________________________________________________

Mailing address__________________________________________________________

City, state, zip___________________________________________________________

Phone: Home_____________________________Cell____________________________
Indicate your registration below:
______ Reception at Sallie Bingham Center 3/30, no charge
______ Conference* only, $60 per person            
______ Reception and dinner only, $50 per person             
______ Conference* and dinner, $110 per person
______ Conference* and dinner, $105 for VFA members
______ Check here to request vegetarian meals 
*includes lunch
Summary of charges
$______________ Conference registration as indicated above
$______________ VFA membership ($50 annually)*
$______________ Donation to defray event costs for those unable to pay*

$______________ Additional donation to support the work of VFA*

$______________ Total                                                *tax-deductible
 
 
Please indicate which payment option you prefer:
_______ Check enclosed made out to VFA. 
_______ Credit card (Visa or MasterCard)
Name on credit card_____________________________________________________

Account number________________________________________________________

Exp. Date______________________________________________________________

Security code____________Signature_______________________________________
 
***A limited amount of financial assistance is available.  If you would like to attend the conference and/or the awards dinner but need financial assistance, please send an email describing your situation to sharingourstories2017@gmail.com. 

Print out the form, indicate form of payment and mail to:
Kathy Rand
813 Mission Creek Drive
Palm Desert, CA 92211
 

Form and payment must be received no later than March 27

 
Please be sure to send in a registration form regardless of your form of payment.
If you are paying by credit card, you may scan and email this form to sharingourstories2017@gmail.com.
 
Photo/Video/Audio Consents and Permissions 
By registering for the VFA conference, I grant permission to VFA and consent to its taking photographs or videos of me or audio recordings of my voice at the event to use, exhibit, display, broadcast and distribute in VFA's sole and absolute discretion, in whole or in part, for profit or otherwise, in any media now known or hereinafter devised, without further consideration, permission, consent or agreement.