AVP/USA 2012 GATHERING REGISTRATION AND
PARTIAL SCHOLARSHIP APPLICATION

(Note: Navigate with TAB or MOUSE.  CR (ENTER) will submit the form.)-

FIRST, REGISTER FOR THE GATHERING:

Name                        Male Female

Adjective Name                     

Street Address       Apt

City     State      Zip

Phone: Home         Work

Cell        E-mail

Name and phone of emergency contact

I would like to share a room with (if double or multiple):

Special Needs (New Windsor is ADA equipped):  Accessible Needs       Special Needs

Describe :

All overnight registrations include meals and Housing.
Daily (commuter) fees include conference program and meals, but not lodging.
Please note: All people enrolling for this conference must be aged 18 by May 15 2012.

CANCELLATION: For a full refund, written requests must be received by April 22, 2012. Requests after this date will be reviewed by AVP MD and AVP USA. No refunds after May 8

 I would like to register for the Three-Day Conference

Three-Day Conference              Early Bird               Regular                 Late
 Lodging and meals                    Before Mar 26         Before Apr 23      Before May 7

    Not staying over-night  

                           Multi/Dorm       $310               $335                $365
                        Dbl/priv. bath       $350               $375                $405
                        Sgl/Priv Bath:      $380               $405                $435

Room Total: $

Three-Day Conference                        Day/Commuter Fee

I would like to register as a day commuter: I will attend  Saturday Sunday Monday

 Days @  $85 per day          =          Day Fee Total: $

Pre-Post Conference Events (Must select same Lodging or Commuter class as 3-day registration)

                                              Not Attending Pre-Conference Events

  Building AVP Communities                 Including Thursday Lodging
  Workshop  (Fri 5/25):            Dorm $130 Dbl $140    Sgl $150        Commuter $90

                                                     Including Wed - Thurs Lodging
  HROC Workshop (Wed - Fri):Dorm $295 Dbl $315    Sgl $335        Commuter $215

                                                               Monday Lodging
  CofC Retreat (Mon 5/28)       Dorm $85  Dbl $95      Sgl $105         Commuter $45
  Not Attending Retreat

Event Total: $

T-shirt Order  (Enter # and calculate total)

  S @ $15   M @ $15   L @ $15   XL @ $15  

  XXL @ $18   XXXL @ $18  

T-shirt Total: $

REGISTRATION TOTAL (use this in calculation of your scholarship request below)  $

Payment by Credit Card  Your Credit Card will not be charged until your scholarship amount is determined and subtracted from your Registration Total.  (If no credit card, you will be billed the balance).

 Mastercard     Visa    No Card

Card Number             Expiration Date

Cardholder Name   Cardholder’s Zip

NOW, REQUEST A PARTIAL SCHOLARSHIP:

Supporting Information

1. First, get local sponsorship and their contribution amount.  Contact your local group/council
    and ask them to send their recommendation and the amount of their financial commitment toward
    your attendance at the conference to scholarship@avpusa.org.

2.  What is your involvement with AVP?  Check all that apply to you:

 Formerly Incarcerated Facilitator
 Current Facilitator   
 AVP/USA Officer -------------------------------- Office:
 AVP/USA Committee Clerk --------- Committee:    
 AVP/USA Committee Member - Committee(s):     
 Conference Presenter ------------------------- Topic:  
 Conference Worker
 First-Time Attendee  

3.  Who in your Local Group is emailing your recommendation and sending in their financial
     contribution for your scholarship?

Sponsoring Local Chapter:   

Chapter Contact Name:        

Chapter Contact Phone:       

Chapter Contact Email:       

If you already have the letter of recommendation from the Local Chapter, cut-and-paste it below. 
If not, or if you are missing other supporting info, complete your application and email the
missing data later to scholarship@avpusa.org.

CALCULATE YOUR SCHOLARSHIP REQUEST

Total Cost:               Registration $       Travel $         Total $

My Resources:   I can pay: $ My Chapter can pay $       Total $

Remainder:                                                          Amount of scholarship request:      $

Share anything else you want us to know about your application for a scholarship:

NEXT STEPS

1.  You will be notified of how much you will receive from AVP/USA, then you will be asked to....

2.  Mail your Local Group donation and your personal contribution to:

     AVPUSA Scholarship Committee
     PO Box 164
     Purchase, NY 10577

     (Instead of a check, we'll charge your personal contribution to a credit card if you entered it above)

3.  On receipt of all monies, you will receive final confirmation of your registration.

 I have checked my entries and am ready to submit my application

   Note: Print this page for your records before submitting.
                                       Click SUBMIT only once and wait for confirmation.