Register for the Dinner to Celebrate the 20th Anniversary of the VA Psychology Leadership Conference
Wednesday, May 17, 2017

The Planning Committee for the VA Psychology Leadership Conference will be celebrating the 20th anniversary of the conference. Please use this page to register for the dinner, indicate any dietary restrictions you would like considered, and submit your payment. NOTE: Please submit a separate registration and a separate payment for each person in your party. After you pay for the dinner through PayPal, you will be directed to a "thank you" page that will have a link to bring you back to this page so you can register additional guests.

Also note: If the name on the credit card you are using to pay for the dinner is different from the name of the registrant, please insert the name that appears on the credit card in the appropriate box at the end of the form so that we may connect this form with the payment.

Thanks for your interest in celebrating the VAPLC!

First Name:  
Last Name:  
E-mail Address:  

If the name of someone other than the registrant named above appears on the credit card being used to pay for the dinner, please enter the name of person that is associated with the credit card in the box below:
Please select one entrée below for your dinner. The event includes a three-course plated dinner with choice of entrée.  Special diet meals available upon advance request.
Chicken: $85.00 (Mozzarella & Prosciutto Stuffed Chicken Breast w/Mascarpone Polenta, Roasted Tomatoes, Sage Pan Jus)
Fish: $85.00 (Oven Roasted Texas Gulf Fish w/Saffron and English Pea Risotto, Broccolini, Tomato, Chili Infused Butter)
Beef: $102.00 (Grilled Filet of Beef w/Roasted Mushrooms, Grilled Asparagus, Shallot Whipped Smoked Gouda Potato)
Vegan: $48.00 (Roasted Vegetable Napoleon  w/Squash Ribbons, Heirloom Tomatoes, Basil Pesto, Blistered Tomato Sauce)
Please list below any dietary considerations you would like the planning committee to ask for the hotel to work towards accommodating in the buffet:

Please click the "Submit" button below to submit your application electronically and to go to an internet site where you can enter your credit card information. Click "Reset" to clear the above information and start over.