Partners In Care Conference - Registration Form

Partners In Care Conference
Registration Form
Please print out and mail no later than:
November 6, 2002 (to receive Early Registration Discount)
or November 25, 2002

Name: _____________________________________
Mailing Address:
Street:_____________________________________
City:__________________State:____ Zip:_________
Daytime Phone:__________________
Email address:_________________________
__ Educator, __ R.N., __ M.D., __ Parent/Grandparent,
__ Parent of child 0 - 3 years, __ Social Worker,
__ Birth to 3 Professional, __ Student, __ Other
Place of Employment:__________________________
Morning Workshops 10:45 - 12:15 (circle or check one:)
__ 1 __ 2 __ 3
Afternoon Workshops 2:45 - 4:15 (circle or check one:)
__ 4 __ 5 __ 6
__ Nursing Contact Hours, __ Social Work Cont. Ed
__ Attendance Certificate

Conference Fee (includes lunch)
$80 - Between Nov 7 - Nov 25, 2002
$70 - Early Registration fee; before Nov 6.
$35 - Parent/Grandparent registration fee.
(Scholarships available for parents and family members;
please call Parent to Parent 1-800-800-4005.)
$35 - Student Rate.
(Non-refundable)

Make check payable to: Parent to Parent of Vermont

and mail the form with payment to:

Delaney Meeting & Event Management
One Main St. #36; Winooski, VT 05404 Fax #: (802)655-6098