WVASN ANNUAL

Conference Registration

Holiday Inn

Bridgeport, WV

November 7- 9, 2007

NAME___________________________________________HOME PHONE (       )__________________
LAST                                                   FIRST                                                    
HOME
ADDRESS_________________________________/___________________________/______/_______
                                STREET OR BOX NO.                                                                  CITY                           STATE             ZIP

WORK
ADDRESS_________________________________/___________________________/_____/_______
STREET OR BOX NO.                                                                CITY                                                            STATE              ZIP

WORK PHONE (         ) __________________ E-MAIL ADDRESS ___________________________________

 EMPLOYER________________________________________________________________________

COUNTY OF EMPLOYMENT_____________________RESA________TITLE/POSITION___________________________

Prefer to receive information AT    _____ HOme                      _____Work

MEMBERSHIP STATUS                                          _______RENEWAL   _______NEW MEMBERSHIP

_____  ACTIVE (Certified school nurse currently working in WV, or working on special permit and working on    certification)

_____   ASSOCIATE (Any nurse with special interest in or are working with the WVASN)

 _____RETIRED (Any retired registered professional nurse)

_____ STUDENT (Any student enrolled to meet requirements to become a school nurse or any student not currently a                 nurse but enrolled in a professional nursing program.  Students must submit proof of enrollment with application   and are limited to 5 years of student membership)

_____   CORPORATE/BUSINESS/PROFESSIONAL ORGANIZATION (Organizations or persons who       desire to support the goals of WVASN and whose members are not eligible for Active or Associate Memberships)

_____ MEMBER-AT-LARGE  (Persons who hold a special interest in or who are working with a                 corporation/business/professional organization and who do not meet the criteria for other classifications)

_____   HONORARY (WVASN Past Presidents or other individuals who have been recognized for significant                     contributions to WVASN)

NASN Member                                              □ Yes □ No

NCSN Certification                                       □ Yes □ No

First Time Conference Attendee                 □ Yes □ No

DUES:   $25.00 FOR ALL ACTIVE MEMBERS        $15.00 FOR ALL OTHER CLASSIFICATIONS

Conference Registration for members is $100.00. Please include appropriate membership dues. Conference registration rate for non-members is $140.00

Those who register after October 18 may not receive complete conference packets.

REGISTRATION INCLUDES:

AM and PM break refreshments, Lunch and Banquet Thursday

Contact Hours – Attendance required

SEND CONFERENCE REGISTRATION TO:

Marion County School Nurses

100 Naomi St.

Fairmont, WV 26554

Make checks payable to WVASN, Inc.

Hotel Registration Information- Mention WVASN for Conference Rate.

A block of rooms has been reserved through 10/8/07.   Please make your reservations promptly!  There is a WVU game Thursday night, Nov. 8, and no rooms will be available for the conference after October 8!!

NOTE:  RESERVATIONS MUST BE MADE BEFORE OCTOBER 8 TO GET CONFERENCE RATE

Holiday Inn 304-842-5411, 100 Lodgeville Rd., Bridgeport, WV

Traveling I 79 North:  Take the 119 exit.  At end of ramp turn right onto Rt. 50 east, at next light turn left.  Holiday Inn on the right.

Traveling I79 South:  Take 119 exit.  At end of ramp turn left onto Rt. 50 east, at third light turn left.  Holiday Inn on right.

Room Rate is $89.00 (plus tax) - single or double occupancy.

 Breakfast is included in room rate.