Fluoride Action Network

The Fifth Citizens’ Conference on Fluoride – REGISTRATION

Conference organized by Fluoride Action Network

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:

Ellen Connett
Fluoride Action Network
104 Walnut Street, Binghamton NY 13905

Name ________________________________________________________

Address _______________________________________________________



Email _________________________________________________________

Cell Phone ______________________________________________________

Registration Fee:

$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.

Amount $________________
By Check ________________
Paid Online______________

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 (ellen@fluoridealert.org) 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.

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