FAN's 6th Citizens’ Conference on Fluoride - REGISTRATION FORM

September 16 – 18, 2017
Hyatt Regency Hotel, Crystal, City, Virginia

Conference Registration Fee:

$40 for students and seniors; $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 below along with this registration form.

Amount $________________
By Check ________________
Paid Online______________

Conference Registration Form:

Please print and fill out this form and mail or email to:

Ellen Connett
Fluoride Action Network
104 Walnut Street, Binghamton NY 13905
Email: ellen@fluoridealert.org

Name ________________________________________________________

Address _______________________________________________________

_____________________________________________________________

Email _________________________________________________________

Group Affiliation_________________________________________________________

Cell Phone ______________________________________________________

Will you be staying at the Hyatt Hotel? ______________________________

Circle the days will you be attending:
Saturday (Sept 16)
Sunday (Sept 17)
Monday (Sept 18)

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 or triple 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.