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Conference Registration Form
Registration deadline is May 10, 1999

What Works, What Doesn't?
Community-Based Research and Strategies for Change

June 11-13, 1999

Name __________________________________________________________________
Organization __________________________________________________________
Mailing Address _______________________________________________________
City ________________ State _______ Zip __________ Country ____________
Phone ______________ Fax ______________ Email _________________________
Website _______________________________________________________________

Registration Fee (Sorry, no credit cards accepted)
___ Regsitration Fee $75.
___ Low Income Fee $25. (e.g. students or community-based organizations)
___ Voluntary contribution to help sponsor a scholarship: amount $_____

Room & Board at Amherst College
___ Thursday night - Sunday afternoon (includes all meals)...$130
___ Friday - Sunday (includes all meals)...$110
___ Thursday afternoon workshop (optional)...$30*
___ Meals only, Friday & Saturday (for commuters with alternative accommodations)...$30 per day
___ Meals only, Sunday (breakfast & lunch)...$15

Would prefer: ___ single room or ___ shared room.
Preferred roommate: ___________________________________________________
___ Enclosed $30 fee to secure single room **

* Conference begins Friday morning. Thursday afternoon workshop "Introduction to Community-Based Research" is optional.
** There are a limited amount of single rooms there we will place people on a first come first serve basis when registration arrives.

Please check all that apply:
___ I require disability access (a Loka staff member will contact you)
___ I have special needs (dietary, environmental, etc.)
    Explain: _________________________________________________________

How did you hear about the conference?
___ Direct Mail ___ Electronic Mail ___ Loka Website ___ Word of Mouth ___ Other

Race/Ethnicity: __________________________________________________________
(Your response is optional but we are interested in ensuring a diverse group of participants.)

Space is limited! You will be contacted by a Loka staff member upon receipt of your registration materials to confirm your registration and to save your space. You will be placed on a waiting list if spaces are full. Please contact us if you prefer not to be placed on the waiting list and we will return your fee.

Please direct checks with all applicable fees to The Loka Institute, and mail to the address below by May 10, 1999. (Loka's federal tax ID # is 04-3334217)

Total Amount Enclosed: $________
___ I am applying for a scholarship (see application enclosed)

Please use the space below to tell us briefly about yourself, your affiliations, and your interests as they relate to community-based research. This information is for inclusion in the participants list. Thank you.

Reminder: Registration deadline is May 10, 1999  

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Up 1999 conf main CRN Conf 1999 1999 Agenda CRN Evaluation Evaluation Registration Scholarship 1999 Report


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This page last modified: October 14, 2004 The Loka Institute