Registration for the 4th Annual

VASN School Nurses’Day at the GA

Thank you for your interest in attending VASN’s Annual School Nurses’ Day at the Virginia General Assembly in Richmond on February 15, 2016. VASN members and non-members are welcome to attend. Our reserved meeting space is limited so registration is on a first-come, first-served basis. To avoid any potential conflict of interest with employers, use your non-work related contact information. VASN will confirm your registration by email on February 5, 201 andprovide additional information prior to the event. Should you have questions about this activity, contact Terry Woody, VASN Legislative Committee Chair,at or 804-874-9201. Walk-ins the day of the program are not available.

PRINT Your Registrant Information

__Michelle Prescott______BSN, RN, NCSN, AE-C______

First and Last Name (As it is to appear on yourcontact hour certificate) Credential (RN, LPN, NP, etc.)

______73296______

Personal Cell Phone Non-work Email VASN/NASN Member Number

_1040 St Lawrence Drive______Chesapeake, VA______23325______

Home Street Address City Zip

_Kenny Alexander_Dist 05______Lionel Spruill Dist 77______

Your Senator's Name and District Number Your Delegate’s Name and District Number

Mentor: Do you wish to have a mentor accompany you on a legislator visit? ⎕No ⎕Yes

Workshop Registration: / VASN/NASN
Member / Non- Member / Nursing Students*
Regular Registration: Includes name badge, presentation materials, legislators’ informational folders, continuing education contact hours, and catered deli box lunch[Includes sandwich, one side dish, 12 oz. soda, and dessert].
Student Registration*: Full time undergraduate nursing students must be accompanied by their instructor. Registration includes catered deli lunch and the educational experience. Attach proof of current enrollment in a university or college nursing program with this registration.
Select one sandwich: ⎕ Smoked ham & Swiss on ciabatta or ⎕ Turkey & Havarti on wheat bread or ⎕ Black bean hummus, avocado & cucumber salad in gluten free flour wrap / $25 / $55 / $15
Refund/Cancellation/Substitution Policy:
Cancellation requests received on or prior to February 8, 2016 are refundable. No refunds will be issued after this date. All changes to an existing registration, including cancellations, must be submitted in writing to VASN’s Treasurer via email at Please note that all refunds will be issued by check. All cancellations will be processed and refunds distributed within 30 days of the close of the workshop. Registrants may substitute another individual from within the same company and pay any difference in registration type. VASN must be notified of any substitutions by phone or email prior to the day of the program.
Virginia Association of School Nurses Payment:
Only checksare accepted for registration. No purchase orders or charge card payments are accepted for program payment. Make your check payable to VASN, Inc. and mail it with completed registration form with your payment to Cynthia Field, VASN Treasurer, 44090 Macedonia Ct., Ashburn, VA 20147-4856. It must be postmarked no later thanFebruary 1, 2016.
Amount Due: $ 25.00 / Check Number: 3571
Questions? Contact Terry Woody, Legislative Chair at or 804-874-9201 / Administrative Use Only – Date Received by VASN Treasurer: