Addiction Studies for Journalists click for image information
Sponsored by Wake Forest University School of Medicine and National Families in Action
 

Register
(Please print and fill out.)

Attendance at the Addiction Studies Program for Journalists workshops is limited. Please register early for the workshop you wish to attend. Hotel lodgings and meals (continental breakfast and lunch on Days 1 and 2; dinner on Day 1) are included in the conference fee.

Full scholarships are available (for conference fee and transportation expenses) for journalists who otherwise cannot afford to attend. To apply, fill out both the Application Form and the Scholarship Form.

Which workshop do you wish to attend?

___ January 10-11, 2005 Workshop
New York, New York

___ June 17-18, 2005 Workshop
Orlando, Florida

___ December 12-13, 2005 Workshop
Tucson, Arizona

___ June 16-17, 2006 Workshop
Scottsdale, Arizona

___ June 15-16, 2007 Workshop
Quebec City, Canada

Application Form
Name

__________________________________________________________________

Position
__________________________________________________________________

Name of Medium
__________________________________________________________________

Address
__________________________________________________________________

City
__________________________________________________________________

State
__________________________________________________________________

Zip
__________________________________________________________________

Phone (Office)
__________________________________________________________________

Fax
__________________________________________________________________

Phone (Home)
__________________________________________________________________

Phone (Cell)
__________________________________________________________________

Pager
__________________________________________________________________

Email
__________________________________________________________________

Kind of news you cover
__________________________________________________________________

__________________________________________________________________

Dietary restrictions, if any
__________________________________________________________________

Conference Fee $95.00.

___ Payment by check or money order is included. (Make check payable to Wake Forest University School of Medicine.)

___ Please charge my credit card for total due.

Credit card type: ___ VISA ___ MasterCard

Credit card number
__________________________________________________________________

Name as it appears on card

__________________________________________________________________

Signature
__________________________________________________________________

Please mail with payment to:

Addiction Studies Program for Journalists
Wake Forest University School of Medicine
Winston-Salem, North Carolina 27157-1083

Or fax (credit card only) to 336-713-7168.

Confirmation of registration and/or scholarship will be received within 1 week after registration deadline. No conference fees can be refunded due to cancellation after confirmation is received. Journalists who receive scholarships and later cancel will be billed for the cost of holding their room and their airline ticket.

For more information call 336-713-7161.

Scholarship Application Form
___ Please accept my application for a scholarship to cover the cost of the $95 conference fee and reimbursement of my transportation expenses after the conference.

I have enclosed:

___ My resume

___ A list of recent stories I have written related to drugs or similar social issues and where they have been published

___ A brief paragraph describing why I want to attend this workshop

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