BUILDING

PARTNERSHIPS IN

OUR COMMUNITY

REGISTRATION

Please print and return this form 10 days prior to the

training. Or you may call or

email Karen Vastine,

VT Center for Crime Victim Services

58 South Main Street

Waterbury, VT 05676

Phone: 802-241-42395

Email: [email protected]

Name: _______

Title: _______

Agency: _______

Address: _______

_______

Phone: _____________

Email: _______

Will you require an accommodation at this conference?

o Interpreter

o Wheelchair seating

o Other: Please specify ____________

o November 9th, Sheraton Hotel, Burlington, VT

o Please email me directions to the training site