Register for the Conference

To register for the 20th Annual VA Psychology Leadership Conference and to pay with a credit card through PayPal, 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 Samuel Wan, Ph.D., Treasurer for AVAPL. Address information for Dr. Wan 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!

Note: If the name on the PayPal account is different from the name of the registrant, please insert the PayPal account 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 April 26 2017. Unfortunately, no refunds will be issued after April 26, 2017. Please do NOT issue a "chargeback" through your credit card company. Please contact Dr. Samuel Wan 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., registrant's spouse or significant other, or if the name on your PayPal account is different from your full name listed above), 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
   
Also, if you're a trainee, will your travel expenses exceed $750?
Yes
No

I am registering to attend the main conference (May 17-19, 2017)
(AVAPL/APA/Division 18 Members: $250; Non-members: $330; Postdoctoral Fellows: $150; Interns: $115)

I am registering to attend the CE workshop:
Compassion Cultivation (May 20, 2017)
(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 5/17 and stay through the duration of the conference on 5/20.
Yes
No

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

If you would like to receive information on how to become more involved with our sponsoring organizations, please indicate by checking one or both below:
AVAPL
APA Division 18

 
Are you a Director of Training?
Yes
No
 
If you are a Director of Training, did you receive funding for your travel expenses to attend this conference?
Yes, full funding.
Yes, partial funding.
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.