September 5 – 8, 2014
Hyatt Regency Hotel, Crystal, City, Virginia
Please fill out this form in PDF or DOC format and mail or email to:
Fluoride Action Network
104 Walnut Street, Binghamton NY 13905
Cell Phone ______________________________________________________
$50 for students; $75 for activists fighting fluoridation; $150 all others. You can pay either by check or online at https://donatenow.networkforgood.org/1415005
Checks payable to Fluoride Action Network. Send to address above.
By Check ________________
Will you be staying at the Hyatt Hotel? ______________________________
Circle the days will you be attending: Saturday (Sept 6) – Sunday (Sept 7) – Monday (Sept 8)
If you want to share a room with another person that you don’t know.
• Ellen (email@example.com) will pair people for the double rooms.
• Only one person can use their credit card to book the room. At the end of the stay the hotel will accept two credit cards so that each person can pay their own share.
• Let Ellen know, either using this form or by emailing her if you are willing to use your credit card for the initial booking.