Registration Form for
YDS’s Mid-South Conference of the
Left
University
of Central
Arkansas
Registration includes housing, conference materials, refreshments
and Friday night social event
Saturday October 15, 2005
Conway
,
Arkansas
Please complete the information below...
Cost (check all that apply):
$15 Regular Pre-Registration
$5 Registration Rate for YDS Members
Free for UCA Students
$10 YDS Membership - Special Conference Rate
I have special financial circumstances and can't pay the above prices
Housing accommodations:
Housing will be provided in local YDS members home for those that need it on Friday and Saturday night. Conference goers are asked to bring their own sheets, pillows and/or sleeping bags). Please remember to bring towels, toiletries and other items to make your stay comfortable.
TYPE OF HOUSING (Check all that apply)
I need free housing
I can afford and prefer to stay at a nearby motel
I do not need housing (live nearby and not staying overnight)
Travel subsidies:
Some financial assistance to cover travel expenses may be available to registered participants. Preference is given to Young Democratic Socialist members and those interested in starting YDS chapters.
I would like to request travel subsidies
I am coming from
(list location)
My estimated cost of travel is
(enter amount)
Enter your information:
First Name
Last Name
Email Address
Address
City/State/Zip
Phone
School (if applicable)
Graduation Date (if applicable)
Organisation (campus, community, and/or union)
Age
YDS Member?
(check all that apply)
Yes
No
Thinking about joining
Interested in starting a chapter
How did you first find out about the conference?
YDS Website
CampusActivism.org
Listserv
Flyer
Friend
other
What are the issues that most interest you?
:
Please enter additional comments or questions below:
Payment method:
(the $15 special pre-registration rate is only available if paid on-line by October 10th $20 at the door)
Pay at the door (not good for pre-registration discount)
Pay on-line with credit card (VISA or Mastercard only)
Once you have completed this form, please click the “Send Form” button below.
**IF YOU ARE PAYING ON-LINE WITH A CREDIT CARD, YOU MUST CLICK ON THE LINK PROVIDED IN THE PAGE THAT FOLLOWS ONCE YOU HAVE SUBMITTED THIS FORM. You will be sent to a separate on-line payment form.