Register for the Workshop
Non-VA Employees

To register for the 22nd Annual VA Psychology Leadership Conference Workshop and to pay with a credit card through PayPal, complete the form below and click the "Submit" button to go to the payment page.

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 you are a VA employee and are registering for the Suicide Prevention Techniques workshop only, please click here.

If your plans change and you are unable to attend the conference after registering, full refunds will be issued if you cancel before May 3, 2019. Unfortunately, no refunds will be issued after May 3, 2019. Please do NOT issue a "chargeback" through your credit card company. Please contact Dr. John McQuaid if you desire a refund.

Thanks for your interest in the workshop!

First Name:  
Last Name:  
Job Title:  
Street Address:  
Address (cont.):  
ZIP Code:  
Work Phone:  
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 are a VA employee or not.
I am not a VA Employee
I am registering to attend the CE workshop:
Suicide Prevention Techniques (May 31, 2019)
(Non-VA employee registrants: $175)

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.