Registration for 2nd Citizens' Conference on Fluoride

Name:_____________________________________________________________________________________________________

Mailing Address___________________________________________________________________________________

__________________________________________________________________________________________________

Home & Cell Phone:________________________________________________________________________________

Email:_____________________________________________________________________________________________

Organization affiliation (if any)

___________________________________________________________________________________________________

Dietary Preference: None / Vegetarian / Vegan _____________________

Amount Paid: $ _____________________________

Conference Costs:
	July 28 Friday	July 29 Saturday	July 30 Sunday	July 31 Monday	August 1 Tuesday	(totals)
Single Room (see Note 1)	$30	$30	$30	$30	n/a
Double Room (see Notes 1,2)	$22	$22	$22	$22	n/a
Breakfast	n/a	$6	$6	$6	$6
Lunch	n/a	$8	$8	n/a	n/a
Dinner	$10	$10	$10	$10	n/a
Conference Fee for FAN Members: $70
Conference Fee for non-members: $100 (see Note 4)
TOTAL (see Notes below)						$

General Conference Rates (Rooms, Meals & Conference Fee)
FAN Member	Friday-Tuesday, Single Room	$ 278.00
FAN Member	Friday-Tuesday, Double Room	$ 246.00
Non-Member	Friday-Tuesday, Single Room (see Note 4)	$ 308.00
Non-Member	Friday-Tuesday, Double Room (see Note 4)	$ 276.00

Notes:

1. Bedrooms.
None of the bedrooms have an attached bathroom. The University provides the following for each guest:
Pillow, blanket, lines (2 sheets & pillow case), Towels, Face cloths

2. Sharing a Bedroom
If you are booking a double room, please write in the name of the individual you wish to share a room with.
If a prefrence is not stated, the Confenece will assign rooms.

3. Day Trip on Monday
After breakfast we will depart campus at 9:15 for a day-trip to Upper Canada village, a charming recreation of a 1860's village, located on the St. Lawrence River. We will return to campus in time for dinner. We will cross the border into Canada and a photo ID is necessary, either a driver's license or passport. Lunch is buy-your-own. There is a hcoice of historical cuisine served in a relaxed heritage setting or fast food deli-fare. For those who want the historical cuisine (and it's very good) reservations are necessary. The cost of a 3-cource lunch is $17.

4. Membership
If you want to become a member of FAN sign-up at http/www.fluoridealert.org and you will be eligible for the FAN membership rate.

5. Refund Policy
If you are unable to attend the Conference, we will send you a refund check with a fee of 10% deducted. However, Conference costs can not be refunded after Friday, July 28.

• CREDIT CARD
Registration fees can be paid by Credit Card or check. For more information see the payment options at http://www.fluoridealert.org/conference/registration.htm

Send Registration to:

FAN Conference
82 Judson Street
Canton NY 13617
Email: conference@fluoridealert.org