Partners In Care Conference - Registration Form

Partners In Care Conference
Registration Form
Please print out and mail with payment no later than:
Nov 18, 2004 (Early Registration Discount) or December 7 [FAX: (802)764-5297]

Name: ___________________________________
Mailing Address: o is Home       or     o is Business
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 AHS Employee
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 C.M.E.
o Attendance Certificate |    o Mental Health Certificate

Conference Fee (includes lunch)
o $80 - Between Nov 19 - Dec 7, 2004
o $70 - Early Registration fee; before Nov 18.
o $65 - Special AHS rate only
o $35 - Parent/Grandparent registration fee.
(Scholarships available for parents and family members; please call Parent to Parent 1-800-800-4005.)
o $35 - Student Rate.

o $0 - Sponsor (limit 1 per org)

o $22 - Exhibitor/Sponsor additional lunches fee

(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

o Please do NOT add me to Parent to Parent's mailing list