The 2005 National Conference on Service in Indian Country

The Fifth National Conference on Service in Indian Country
Preserving the Past.Creating our Future:
Resources for Strengthening our Communities

A conference designed to unite and reinforce Tribes,
Service Programs, and Partners in their work to strengthen Communities

Registration Form

Type of Organization:
Tribal Government	Non-profit Organization	Interested Individual
Tribal Planners	Foundation	Federal/State/Local Public Agency
Tribal Programs	Corporation	Other

Name:

First

Middle Initial

Last

Title:

Organization:

Address:

City:

State:

Zip Code:

Phone:

Fax:

E-mail :

Do you currently participate in a Corporation for National and Community Service sponsored program? Yes No

If yes, indicate program(s):	AmeriCorps Tribal Set-Aside Program
	AmeriCorps Tribal Civilian Community Corps
	AmeriCorps Vista
	AmeriCorps State and National
	AmeriCorps Promise Fellows Program
	AmeriCorps Education Award Program
	AmeriCorps NCCC
	Learn and Serve America
	Senior Corps Foster Grandparents
	Senior Corps Senior Companions
	Senior Corps RSVP (Retired and Senior Volunteer Program)
	Other

If you or your guests have disabilities that require specific accomodations to ensure your full participation in this conference, please check here. Someone will contact you regarding your requirements.

Any dietary requirements? Yes No If you have dietary requirements, someone will contact you.

Registration Fee: $175.00