First Name*

Last Name*

Email Address*

Cell Phone Number*

Congressional District State / Number*

For example, you can write in California 5th District or CA 5. If you are from DC, you can write in “No Taxation without Representation”. For example, you can write in California 5th District or CA 5. If you are from DC, you can write in “No Taxation without Representation”. For example, you can write in California 5th District or CA 5. If you are from DC, you can write in “No Taxation without Representation”.

Which city do you live in?

Dietary Restrictions

Will you be working with an ANA group to prepare for DC Days?* Will you be working with an ANA group to prepare for DC Days?* Yes No

If so, which group? If so, which group?BEYOND NUCLEARBLUE RIDGE ENVIRONMENTAL DEFENSE LEAGUECOLORADO COALITION FOR THE PREVENTION OF NUCLEAR WARCONCERNED CITIZENS FOR NUCLEAR SAFETYFERNALD RESIDENTS FOR ENVIRONMENTAL SAFETY AND HEALTHGEORGIA WOMEN’S ACTION FOR NEW DIRECTIONSHANFORD CHALLENGEHEART OF AMERICA NORTHWESTJUSTPEACENUCLEAR WATCH NEW MEXICOMIAMISBURG ENVIRONMENTAL SAFETY & HEALTHNUCLEAR AGE PEACE FOUNDATIONNUCLEAR WATCH SOUTHOAK RIDGE ENVIRONMENTAL PEACE ALLIANCEPARENTS AGAINST SANTA SUSANA FIELD LABORATORYPEACE ACTIONPEACE FARMPEACEWORKS KANSAS CITYPHYSICIANS FOR SOCIAL RESPONSIBILITYPHYSICIANS FOR SOCIAL RESPONSIBILITY – LOS ANGELESPHYSICIANS FOR SOCIAL RESPONSIBILITY – KANSAS CITYPRESS (Portsmouth/Piketon Residents for Environmental Safety and Security)ROCKY MOUNTAIN PEACE & JUSTICE CENTERSAVANNAH RIVER SITE WATCHSNAKE RIVER ALLIANCESOUTHWEST RESEARCH AND INFORMATION CENTERTRI-VALLEY COMMUNITIES AGAINST A RADIOACTIVE ENVIRONMENTWOMEN’S ACTION FOR NEW DIRECTIONSWOMEN’S INTERNATIONAL LEAGUE FOR PEACE AND FREEDOMOTHER (Please note below)

Other unique needs/notes

Have you attended DC Days before?* Have you attended DC Days before?* Yes No

If yes, which years?

Do you plan to apply for a scholarship? Do you plan to apply for a scholarship? Click here if yes (then continue to submit and skip payment at this time)

PAYMENT PAYMENT For example, you can write in California 5th District or CA 5. If you are from DC, you can write in “No Taxation without Representation”.

PAYING BY CHECK? PAYING BY CHECK? Please check here if you prefer to pay by check.

Please send check to: Please send check to: For example, you can write in California 5th District or CA 5. If you are from DC, you can write in “No Taxation without Representation”.

Jennifer Viereck Jennifer Viereck For example, you can write in California 5th District or CA 5. If you are from DC, you can write in “No Taxation without Representation”.

PO Box 1403 PO Box 1403 For example, you can write in California 5th District or CA 5. If you are from DC, you can write in “No Taxation without Representation”.

Abiquiu NM 87510 Abiquiu NM 87510 For example, you can write in California 5th District or CA 5. If you are from DC, you can write in “No Taxation without Representation”.

REGISTRATION COST: REGISTRATION COST: For example, you can write in California 5th District or CA 5. If you are from DC, you can write in “No Taxation without Representation”.

- Student/Under 30 to Under 30 or BIPOC or Frontline Communities Registration (prior to April 1): $150 - Student/Under 30 to Under 30 or BIPOC or Frontline Communities Registration (prior to April 1): $150 For example, you can write in California 5th District or CA 5. If you are from DC, you can write in “No Taxation without Representation”.

- Regular Registration (Prior to April 1): $200 - Regular Registration (Prior to April 1): $200 For example, you can write in California 5th District or CA 5. If you are from DC, you can write in “No Taxation without Representation”.

- Student/Under 30 to Under 30 or BIPOC or Frontline Communities Registration (after April 1): $225 - Student/Under 30 to Under 30 or BIPOC or Frontline Communities Registration (after April 1): $225 For example, you can write in California 5th District or CA 5. If you are from DC, you can write in “No Taxation without Representation”.

- Regular Registration (after April 1): $350 - Regular Registration (after April 1): $350 For example, you can write in California 5th District or CA 5. If you are from DC, you can write in “No Taxation without Representation”.

If paying by card, please submit this form first and continue below to pay online If paying by card, please submit this form first and continue below to pay online For example, you can write in California 5th District or CA 5. If you are from DC, you can write in “No Taxation without Representation”.