Register for the Conference

Deadline to register: March 9, 2012

To register for the 15th Annual VA Psychology Leadership Conference and to pay with a credit card through Amazon Payments, complete the form below and click the "Submit" button to go to the payment page. If you would prefer to pay for the conference by check, download this registration form by clicking on the link in the column to the left, complete the form, and mail it along with your check (payable to AVAPL) to Ann Landes, Ph.D., Treasurer for AVAPL. The address for Dr. Landes appears on the downloadable registration form. NOTE: Space at this conference is limited. Once the maximum number of participants has registered, registration will close, and a waiting list will be kept. Be sure to register early to ensure your attendance!

Also note: If you are completing this registration form for another person, please insert your name in the appropriate box at the end of the form so that we may connect this form with the payment.

If your plans change and you are unable to attend the conference after registering, full refunds will be issued if you cancel before March 9, 2012. Unfortunately, no refunds will be issued after March 9, 2012. Please do NOT issue a "chargeback" through your credit card company. Please contact Dr. Ann Landes if you desire a refund.

Thanks for your interest in the conference!

First Name:  
Last Name:  
Degree:  
Job Title:  
Facility:  
Location:  
Street Address:  
Address (cont.):  
City:  
State:  
ZIP Code:  
Work Phone:  
FAX:  
E-mail Address:  

If someone other than the registrant named above will be paying the registration fees (e.g., facility Education Office; registrant's spouse), please enter the name of person that is associated with the credit card being used to charge the registration fee in the box below:
 
   
Please indicate whether you belong to the organization(s) listed below. Click in the checkboxes for all that apply to you.
Member, Association of VA Psychologist Leaders
Member, American Psychological Association
Member, APA Division 18
   
If you're a trainee, please indicate whether you're an Intern or a Postdoctoral Fellow:
Psychology Intern
Psychology Postdoctoral Fellow

I am registering to attend the main conference (April 12-13, 2012)
(AVAPL/APA/Division 18 Members: $250; Non-members: $330; Postdoctoral Fellows: $150; Interns: $115)

I am registering to attend the following Saturday workshop:
Workshop 1 (April 14, 2012): VA Integrated Ethics: Advancing the
               Transformation of Ethics Quality in Health Care
Workshop 2 (April 14, 2012): Developing and Implementing a
              Telemental Health Program
(All registrants: $75)

Is this your first time to attend the VA Psychology Leadership Conference?

Yes
No

VA Trainees Only: Would you be interested in volunteering at the conference for a $300 scholarship? In order to qualify, you must be able to arrive early on 4/12 and stay through the duration of the conference on 4/14.

Yes
No

Are you an Early Career Psychologist? Click "yes" if you are five years or less from the receipt of your degree.
Yes
No
 
 
 

If you would like to pay by credit card, 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.