First Name:
Last Name:
Company or Organization:
Title:
Department or Program:
Address:
Address Line 2:
City:
State:
Zip / Postal Code:
Phone:
Fax #:
Email:
We may include photos of Institute participants on our website and project
display board. To protect your privacy, if you do not wish to have your photograph
included,
please check this box and inform the registration staff when you arrive at the conference.
Do not include my photo .
Registration Cost
(Includes full Institute, lunch on Wednesday and brunch on Friday).
Please check
appropriate boxes:
$95 Early Bird Registration, by
October 15, 2010 Extended through October
22, 2010!!!
$125 Regular Registration,
October 23 - November 19, 2010
(no onsite registration)
Deduct $5 per registration for
three or more participants from the same organization registering together!
You must submit a separate registration form for each participant. Check the
box then list
the names of the additional participants here to insure that you receive the
discount:
To help us plan
conference materials and seating, please check each day below that you plan
to attend.
I have the following food allergies:
I prefer a vegetarian meal
Special Registration:
If you are an
Institute Presenter ,
Exhibitor ,
Sponsor , Facilitator , or Institute Staff , please check the appropriate box above and follow the
separate instructions you received when computing conference registration
fees. You do need to register so we will have your Institute
materials and to include you in the meal counts. For questions, please contact Brenda Reynolds at 501-922-1880 or reynoldsbrendak@uams.edu .
Payment Information:
Check, money order or purchase order must accompany registration. Payment should be made to
UAMS Welcome the Children .
Compute total cost below based on
registration date and any special registration arrangements.
Total Registration Cost $
(Arkansas State agencies, please contact Barbara Whitehead at 501-682-9900
or 800-342-2923 if you need additional vendor information.)
Once your registration form and payment have been received, you will receive written confirmation of your registration. You are not fully registered until your receive your confirmation. Please indicate your preference for notification of registration confirmation.
E-mail
Regular Mail
Fax