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Nursing Annual Research Conference
Online Registration Form
(* required fields)
Registrant Information
Name:
*
(Full Name)
Mailing/Address:
*
City:
*
State:
*
-- UNITED STATES --
Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
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Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
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Nevada (NV)
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Utah (UT)
Vermont (VT)
Virginia (VA)
Virgin Islands (VI)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
-- CANADA --
Alberta (AB)
British Columbia (BC)
Manitoba (MB)
New Brunswick (NB)
Newfoundland and Labrador (NL)
Northwest Territories (NT)
Nova Scotia (NS)
Nunavut (NU)
Prince Edward Island (PE)
Saskatchewan (SK)
Ontario (ON)
Quebec (QC)
Yukon (YT)
Zip:
*
Daytime Phone:
*
Email Address:
*
Nursing Continuing Education Credit Requested?
Yes
No
Prefer written confirmation:
Yes
No
Request driving information/map:
Yes
No
Food Allergies:
I Plan to Attend
All breakdown sessions presentations will be repeated after the lunch. Please indicate your first and second choice for each session. Session assignnments will be made on a "first come first served" basis.
Choice 1
Choice 2
Morning
Afternoon
Morning
Afternoon
Childhood Obesity - Nutrition
CATCH Pediatric Mobile Team
The Sports Pre-Participation Physical Evaluation
Tansition from Pediatrics to Adult Medicine
Before 8/28/09
After 8/28/09
Individual Fee
Student Fee
$ 75
$ 35
$ 100
$ 50
Method of Payment
Total Amount:
$
Credit Card type:
AmericanExpress
Discover
MasterCard
Visa
Name on the Card:
Credit Card Number:
Exp Month:
(mm)
Exp Year:
(yyyy)
Billing Zip Code:
Registration fee for scientific session includes continental breakfast, lunch, breaks and all course materials. A $25 service fee will be charged for refunds requested in writing, postmarked on or before September 12, 2009. No refunds will be made after September 12; however, substitutions will be accepted.
Handout materials, break refreshments or lunch will not be available without preregistration.
Questions? Contact Delphine White at
dwhite@dmc.org
or (313)745-5458.
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