Brazos Valley

                                  Crime Victims Rights Week

                                                         REGISTRATION FORM

Registration fee is $10 (fee includes lunch both days & t-shirt)

Registration Fee & Form Due April 1, 2008

 Please type clearly and complete all requested information.

Submit One Form Per Attendee 

ATTENDEE CONTACT INFORMATION

Name:                                                 Title:

Agency:

Address:

City:                                        State:                         Zip Code:

Phone:                        Fax:                             Email:

DOB (peace officers only)                                       PID# (peace officers only):

State Bar card # (attorneys only):

Check professional discipline          

[   ]Attorney                                         [   ]CASA                    [   ]District Attorney’s Ofc.

[   ]Child Advocacy Center               [   ]CPS                       [   ]Education

[   ]Law Enforcement                         [   ]Medical                 [   ]Social Services

[   ]Mental Health                                [   ]Other:                                                                      

 

MEAL INFORMATION AND SPECIAL REQUESTS:

I am planning to attend:        [   ] Wednesday Keynote Lunch

                                                [   ] Thursday Keynote Lunch

                                                [   ] Candlelight Vigil (Thursday)

 T-shirt size:    [   ]S                [   ]M                [   ]L                 [   ]XL            

[   ]2XL            [   ] 3XL 

Conference Information

WHEN: April 16th & 17th, 2008

WHERE: A&M Church of Christ

2475 Earl Rudder Freeway          College Station, TX 77845

CONTACT INFORMATION: Rape Crisis Center, Brazos Valley, 979-731-1000 

RETURN COMPLETED REGISTRATION FORM AND REGISTRATION FEE TO:

Rape Crisis Center, Brazos Valley

c/o Laury Kasowski

P.O. Box 3082

Bryan, TX 77805

Please make checks payable to BCRCC