Annual Meeting Registration

Tuesday, June 4th, 2013
Lecture, discussion, dinner.
5:30 - 8:00pm
Capitol Plaza - Montpelier, VT
register for the annual meeting


Building Healthy Families:

Learning the Vermont Based Family Approach with Dr. Jim Hudziak and local efforts about overcoming adverse childhood experiences. As Director of the Vermont Center for Children, Youth & Families, Dr. Hudziak has developed a non-medical intervention that engages the whole family and works towards changing the environment for at-risk individuals.

VtPHA Members: $10
Non-Members (all welcome): $25
Seating Limited

Dinner selections (they need to indicate when they sign up): Chicken
Vegetarian
If you prefer to send a check, please contact Honey Resto, honey.resto@vtmednet.org.



Personal Information:

*Contact Name:
*Email:
*Phone:
*Street:
*City:
*State:
*Zip Code:
Affiliations:
   

Dinner Selection:

 
What would you like for Dinner? Vegetarian Chicken
   

Membership Information:

 
Are you currently a VtPHA Member? Yes No
If not, would you like to join VtPHA? Yes No

If yes, Please select the category of membership you would like below. Otherwise skip directly to the Payment Section.
   

New Memberships:


vtphaPlease select a category
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 Not A Member? Join Now!

Regular ($35.00)
Student ($20.00)
Retired ($20.00)
  Sustaining Member ($100.00) can name four individuals to represent them in VtPHA. The four members will have all the rights and privileges of individual members. The names of sustaining members will be prominently displayed on the VtPHA website and on any VtPHA promotional materials. They will also be publicly recognized at the Annual Meeting.
vtphaNames of sustaining members
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Payment Information

visa or mastercard

Your Credit Card will be charged by the Vermont Public Health Association for the amount you indicate by the way you fill out this Registration Form.
  • VtPHA Members $10.00
  • Non VtPHA Members $25.00
  • New Members will be charged the Membership Fee Selected Above and Member Fee of $10, for the event.

Credit Card: Visa Mastercard Discover
Cardholder's Name:
Credit Card Number:
Expiration Date:   (Month/Year)
CVC Number:   CVC on back of card
Question or comments here: