Asheboro!

Symposium 2005
REGISTRATION

Join us

Jan 29 - Jan 30
This online registration form is for the convenience of our members. Since we are not equipped to accept payment online, confirmation and payment will be by regular mail. Complete and print the form below and then mail the form and your check to WRNC, c/o Carla Johnson,
2542 Weymoth Rd., Winston-Salem, NC 27103.  If you wish to qualify for "early bird" rates, the envelope with the registrations form and payment must be postmarked by the cut-off date of January 10, 2005.

Payment Schedule
 
Rec'd by Jan 10
Rec'd after Jan 10
Registration when 2005 Membership already paid
$25
$35

Registration for Non-member
$40
$50
Registration & 2005 Membership
$40
$50
Name: Address:
City/Town: State: Zip Code:
Telephone: E-mail Address:
Do you plan to attend the Icebreaker (Friday 7pm)?.......... Yes    No
Do you wish to sign up for a Sub-Q workshop?............... Yes    No
Do you wish to sign up for a fecal workshop, if one can be arranged?............ Yes    No
Complete this section if you are paying your membership fee with your registration. The membership fee is $15.
Home Phone: County:
Work Phone: District:
Are you a new member or are you renewing your membership?   New    Renewing
WRNC publishes a membership directory. It enables us to refer callers to one another or seek help if we need it. Do you want to be listed in the membership directory? Yes   No
Answer the remaining questions if you wish to be listed in the membership directory.
Do you have a current state rehabilitation permit?      Yes     No
Do you have a current federal rehabilitation permit?     Yes     No    ( If yes, please include a copy)
Do you work out of a center or independently at your home?______________________________
Do you have a membership in the International Wildlife Rehabilitation Council (IWRC), the National Wildlife Rehabilitators Association (NWRA), or any other state or local rehabilitation groups? Please list: __________________________________________________
How long have you been rehabilitating? _________________
Which groups of animals do you rehabilitate? Check all that apply and write in exceptions, if any. If you do not have a federal permit, we cannot list you as accepting birds.
    Small mammals including opossums
    Mid-size mammals (river otter, bobcat, beaver, woodchuck)
    Songbirds     Seabirds     Raptors     Wading Birds     Waterfowl
    Reptiles/Amphibians       If yes, do you accept venomous snakes?     Yes No
Note: Wildlife is not permitted in the Education Building. Please do not bring any wildlife.
Thank You. We look forward to meeting you at the symposium.