Dakota Conference on Rural and Public Health

2015 Registration

Register below, or use this printable registration form.
Deadline to register online: May 22, 2015.

Early Bird Registration

Registration forms AND payment must be received by May 5, 2015 to receive the discounted registration.
* indicates required field
Contact Information
Name*
Position/Title
Organization
Work Mailing Address*
City*
State*
Zip*
Phone*
E-mail*
   
As part of participating in the Dakota Conference on Rural and Public Health, your contact information will be shared with other participants and the Dakota Conference paid sponsors and exhibitors. Your information may also be used to contact you for special events occurring during the conference. Your contact information will not be sold. Please contact Kylie at kylie.nissen@med.und.edu if you have questions.
     I wish to opt out of having my contact information included.

Meals
Please select meals that you will be attending:
Tuesday, June 2
Lunch
PM Break
Reception
Wednesday, June 3
Breakfast
AM Break
Lunch
PM Break
Thursday, June 4
Breakfast
AM Break

Registration Fees
Registration forms AND payment must be received by
May 5, 2015 to receive the discounted registration.
Early
 Bird
    Registration
Full Conference Registration $225 $275
Third Person, same organization
NOTE: Each person registering for the third-person rate must be accompanied by two full conference registrations (i.e., Person 1: full conf; Person 2: full conf.; Person 3: 3rd person; Person 4: full conf., etc.). In order to receive the third person discount rate all registration forms must be sent together. If the third person registration is not accompanied by two full conference registrations, they will not qualify for the group discount rate and will be charged full conference price. In order to qualify for the third person discount when registering online, the third person and two full conference registrations must all be received within 30 minutes of one another. If you have questions about third person registration, please call Kylie at 701-777-5380.
$200  
Presenter Registration $200 $250
One Day Only, Specify which day:    
Tuesday Only $150 $200
Wednesday Only $150 $200
Thursday Only $100 $150
Student Registration
To qualify as a student, you must be registered as a full-time student.
$50 $75
Not attending the conference $0 $0
Banquet Tickets - evening of June 3    
Ticket for registrant $15 $25
Additional Tickets   # of tickets $25 $30
Extras  
I will be attending the Critical Access Hospital (CAH) Workshop
June 2, 8:00 – 11:30am
     Cost is $15 each. # attending
 
 
I will be attending the North Dakota Public Health Association Meeting
June 2, 8:30 – 11:30am - no charge
 
 
I will be attending the North Dakota Rural Health Association Meeting
June 3, 7:00 – 8:00am - no charge
 
 
Please provide a written request for any special needs (including dietary):
 

Scholarships Are Available!
Visit ruralhealth.und.edu/dakota-conference/scholarships by March 25, 2015 to apply.

Payment Method
Amount Due $0
Please send me an invoice (invoices will be emailed)
Credit Card
We accept Visa, MasterCard, Discover, & Electronic Checks
Check #
Please make check payable to UND

Mail to:

Kylie Nissen, Senior Project Assistant
UND Center for Rural Health
501 N. Columbia Rd. Stop 9037
Grand Forks, ND 58202-9037
Fax: 701-777-6779

 

Phone: (701) 777-3848
Email: ruralhealth@med.und.edu

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