Name

Additional Registrants:

Special Needs:
Vegetarian Meal
ADA Accommodations (please specify)

If you represent a service organization, please complete the following information about the organization. Information must be provided by Sept. 15, 2009 to be included in the booklet of services that will be distributed at the Forum.

Organization was included in the Booklet in 2008, and the information has not changed.

Brief Mission Statement (75 words or less)

Check which services your organization provides:

Campaign Assistance	Hospice	Scholarships
Childcare Assistance	Housing Assistance	Scholarship Counseling
Counseling	Immigration Assistance	Senior Services
Domestic Violence/Abuse	Job Placement	Tax Assistance
Family Services	Job Training	Teen Services
Financial Assistance	Labor Representation	Transportation Assistance
Financial Planning	Leadership Training	Tutoring
Grants for Individuals	Legal Assistance	Volunteering
Grants for Organizations	Legislative Assistance	Other:
Health Care	Mentoring
Health Education	Parent Education

Does your organization offer scholarships or grants?        Yes      No

If yes, please fill in the following information:

Eligibility Requirements


Contact Name


Phone


Registration Fee:
    Thru Sept 26: $35 per person
    After Sept 26: $40 per person
    Student with ID: $20 per person

Check your method of payment:
I will mail a check separately to VCWFC, PO Box 7362, Ventura, CA 93006. Make checks to: NWPC-CA WLF with "VCWFC Vta Co Restricted Funds" in the Memo Line.

Amount

I will submit an on-line payment using a link to paypal on the next page.

Amount

Amount intended for Registration:
Amount intended as tax-deductible donation to VC Women's Forum:
Non-Profit 501(c)(3)Tax ID: 33-0019914

For additional information: (805) 639-3886