19Th Annual VA Psychology Leadership Conference Registration

19TH ANNUAL VA PSYCHOLOGY LEADERSHIP CONFERENCE REGISTRATION SAN ANTONIO, TEXAS, MAY 31 – JUNE 3, 2016 Please register and pay online, if possible, at http://conference.avapl.org.

REGISTRATION FEE MUST ACCOMPANY THIS FORM TO RESERVE YOUR SPOT First Name: ______Last Name: ______Degree ______Job Title: ______Facility: ______Location (VISN, VACO): ______Address: ______City: ______State: ______ZIP Code: ______Work Phone: ______FAX: ______E-Mail: ______

 Is this your first time to attend this conference? (Please circle) Yes No  Are you an Early Career Psychologist? (10 years or less from the receipt of your degree) (Please circle) Yes No  If you would you like to receive information on how to become more involved with our sponsoring organizations, please indicate by checking one or both below: ____ AVAPL ____ APA Division 18 (Psychologists in Public Service)  Special dietary needs (e.g., diabetic, gluten-free). Please specify: ______

Please indicate your status below: _____ APA/AVAPL/Div 18 Member (Conference: $250; Workshop: $75; Both: $325) In order to get this reduced rate for membership, please indicate which organization you are a member of (check all that apply): ____ APA _____ AVAPL _____APA Division 18 _____ Non-Member of APA/AVAPL/Division 18 (Conference: $330; Workshop: $75; Both: $405) _____ Postdoctoral Fellow* (Conference: $150; Workshop: $75; Both: $225) _____ Psychology Intern* (Conference: $115; Workshop: $75; Both: $190) *VA Trainees: _____ Check here if you are interested in volunteering at the conference for a $300 scholarship. In order to qualify, you must be able to arrive early on the 31st and stay through the duration of the conference on the 3rd.

Optional: Tribute Dinner for Dr. Kathy McNamara (select one entrée below): Event includes three-course plated dinner with choice of entrée. Special diet meals available upon advance request. ____ Chicken: $82.00 (Pan Seared Chicken Breast with Wilted Greens, Fingerling Potatoes, Thyme Lemon Pan Jus) ____ Fish: $85.00 (Pan Seared Salmon with Lobster Mashed Potato, Caramelized Onions, Fennel Tomato Cream Sauce) ____ Meat: $98.00 (Grilled New York Steak with Pancetta Butter, Garlic Whipped Potatoes, Cabernet Demi Glaze) ____ Vegan: $48.00 (Wild Mushroom & Herb Risotto with Grilled Asparagus, Roasted Tomato Pesto, White Truffle Essence)

I am registering to attend the following (check all that apply): Event Cost ____ Main conference (5/31 – 6/2/2016) $ ______Workshop: Behavioral Health Leadership Training Boot Camp (6/3/2016) $ ______Tribute Dinner for Dr. Kathy McNamara (5/31/2016) $ ______Total Enclosed: $ ______This registration form and your payment must be received no later than May 9, 2016. Mail your completed registration form along with your check, payable to AVAPL with “19th Annual VA Psychology Leadership Conference” in the memo line, to Mary Beth Shea, Ph.D., Treasurer, AVAPL. Please e-mail Dr. Shea at [email protected] for the mailing address.

Questions? Please contact Conference Chair, Amee Patel, Ph.D., at [email protected]. PLEASE NOTE: LIMITED SLOTS ARE AVAILABLE. REGISTRATION WILL CLOSE ONCE SLOTS ARE FILLED. If your plans change and you are unable to attend the conference after registering, full refunds will be issued if you cancel before May 9, 2016. Unfortunately, no refunds will be issued after May 9, 2016. CONTACT HOTEL FOR RESERVATIONS (PLEASE DO NOT CONTACT AVAPL) The Westin Riverwalk Hotel located at 420 West Market Street, San Antonio, TX 78205 Phone: 210.224.6500 / Online Hotel Reservation link at http://conference.avapl.org