2012 registration form

2012 VMATYC conference registration

Lord Fairfax Community College, Middletown, VA

March 30-31, 2012

* means required field

name*

Position*

full time faculty
adjunct faculty
student
administrator
other

college*

college address*

city, state, zip*

work phone*

work email*

home address*

home city, state, zip*

home phone

home email

preferred mailing address*

college
home

REGISTRATION

basic registration (check only one box)*

current VMATYC member $25
current VMATYC member making presentation $12.50(only one person per presentation may pay this fee; does not apply to roundtable leaders or presiders)
current VMATYC student member $10
non-VMATYC member $35 (includes $10 for dues)
non-VMATYC member making presentation $22.50 (only one person per presentation may pay this fee; does not apply to roundtable leaders or presiders; includes $10 for duex)
non-VMATYC member student $12 (includes $2 for dues)

Late registration

I am registering after March 9. Late fee $10

membership dues for next year (optional)

regular, $10
student, $2

contribution to VMATYC scholarship fund (optional)

DINNER NON CONFERENCE GUESTS

number of non-conference guests at Friday night dinner

total cost for non-conference guests at Friday night dinner, $12 each

names of non-conference dinner guests

TOTAL AMOUNT - please add*

OTHER DINNER/LUNCH INFORMATION

Special dietary requests

i will be attending the Friday night dinner*

yes
no

I will be attending the Saturday lunch*

yes
no

Please write down the total amount. When you click the submit button below, you will go to a page on which you can pay the total using Paypal. You do not need a Paypal account to use Paypal - you can be a Paypal "guest." If you would rather not pay online, please send your check to: Karen Walters, Mathematics. NVCC, 8333 Little River Turnpike, Annandale, VA, 22003

Refund (minus $1.50 charge) is available if requested by March 23, 2012.

payment method

Paypal
check