Partners In Care Conference - Registration Form

Partners In Care Conference
Registration Form
Please print out and mail with payment no later than:
November 7, 2003 (to receive Early Registration Discount)
or November 25, 2003 [FAX: (802)764-5297]

Name: _____________________________________
Mailing Address:
Street:________________________________
City:_________________State:___ Zip:________
Daytime Phone:__________________
Email address:_________________________
Check all that apply:
o Educator   |   o R.N.    |     o M.D.    |    o OT/PT
o Parent/Guardian    |    o Parent of child Birth to 3 years
o Social Worker      |   o Birth to 3 Professional
o Student    |      o Childcare Provider
o Other
Place of Employment:_____________________
Morning Workshops 10:45 - 12:15 (choose one)
o 1      |       o 2       |       o 3
Afternoon Workshops 2:45 - 4:15 (choose one)
o 4     |       o 5       |       o 6
o Nursing Contact Hours |   o Social Work Cont. Ed
o Attendance Certificate |    o Mental Health 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:
Parent to Parent of Vermont
600 Blair Park Road, Suite #240
Williston, VT 05495-7549