REGISTRATION

[Please PRINT]

Social Justice Conference 2005

Registration Form

Name                                                                                                                                     

Address                                                                                                                                 

City                                                                 State                            Zip                              

Affiliation/Organization                                                                                                    

Telephone (day)                                                                                                                   

E-mail                                                                                                                                   

Choose ONE Workshop:                  1           2           3           4           5           6

Other special needs to be accommodated:                                                      

Interest in Continuing Education Unit Yes            Agency                                               

Check: Please make payable to Vincentian Center/St. John's University

Credit Card: Please indicate card type: MC / VISA / DISCOVER / AMEX

(Credit Card registrations may be faxed to 718/990-1901)

Please print clearly

Card Number:                                                                                                                         

Expiration Date                                                                                                                       

Name of Cardholder                                                                                                                

Signature of Cardholder                                                                                                         

Address                                                                                                                                   

City                                                      State                                         Zip                              

Day Phone No.                                                                                                                       

Email                                                                                                                                       

Conference Fees

(Includes Materials, Continental Breakfast, Lunch, & Refreshments)

Individuals      

$40 If Received By Oct. 1, 2005

$45 After Oct. 1, 2005

Students    (ID Required)      

$20 If Received By Oct. 1, 2005

$25 After Oct. 1, 2005

Group Rate - Five or More   (Must register as group, at the same time)

$35 if received by Oct. 1, 2005

$40 after Oct. 1, 2005

Space is limited! Register early!

Complete One Registration Form Per Person

[Group Registrations, Please Attach All Registrants].  

Mail form with your check payable to Vincentian Center/ St. John's University to: Vincentian Center for Church and Society

St. John's University

St. Vincent's Hall Room 108A

J amaica, NY   11439

For additional information:

vccs@stjohns.edu

718.990.1612

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