Name____________________________________________________________ (please print) Credentials (only 2 please)______________________________________________ Phone (day )__________________(Evening)__________________ Your Email________________ Address________________________________________________________________ City______________________________ State_______________ ZIP______________ ____Section A $230 Thursday & Friday (Thursday lunch included) ____Section B $135 Thursday (Lunch included) ____Vegetarian lunch ____Section C $115 Friday (Lunch on your own) Late Fee: Add $50 after March 1st ____Check here if payment is from employer. Submit a completed registration form NOW. Your space will be held until 3/2/08 (pending receipt of payment). Make Check Payable to: The New Mexico Breastfeeding Task Force Payment Method ____check ____Visa ____MC Total $____________ Credit Card #______________________________________Exp Date_____________ Name on Card___________________________________________ Signature_______________________________________________ --------------------------------------------------------------------------------------------------------------------------- Registration: Fax: 505-237-1542; Mail: 8801 Lagrima de Oro NE, Albuquerque, NM 87111 Refund: Your fee, minus a $25 cancellation fee, will be refunded only if a written request is received by March 5, 2008 . Participants with special needs: Participants requiring special accommodations should contact our conference planner, Jacie Coryell at 505-293-5215 |
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Conference Registration Form |