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Registration

Submission Deadline: March 19, 2010
* indicates required field
Contact Information
Name*
Position/Title*
Organization*
Work Mailing Address*
City/State/Zip*
Phone*
Fax
Email*
   
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 knissen@medicine.nodak.edu if you have questions.
  I wish to opt out of having my contact information included.

Registration Fees
Full Conference = $195 (paid on or before March 19, 2010)
On-site Registration = $220 (paid after March 19, 2010)
Third Person same organization = $170
Note: All registrations must be sent together to receive group discount rate. 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.)

List first 2 full-conference registrants:
* (required)

* (required)
Presenter Registration = $130
Student Registration = $35  (To qualify as a student, you must be registered for a minimum of 12 credits)
One Day Only = $130, Specify which day: Tuesday Wednesday
Thursday Only = $75
Banquet (with registration) = $10
Banquet (without registration) = $25     # of tickets

Pre-Conferences:
Critical Access Hospital (CAH) Workshop
April 13, 2010; 8:00 a.m.–12:30 p.m.
North Dakota Public Health Association Meeting
April 13, 2010; 8:00 a.m.–11:30 a.m.
   
Please provide a written request for any special needs (including dietary):

Yoga:
I will be attending on Wednesday, April 14, 2010; 6:45 a.m.–7:30 a.m.
no charge
I will be attending on Thursday, April 15, 2010; 6:45 a.m.–7:30 a.m.
no charge

Payment Method
Please send me an invoice
Check # enclosed for $
Please make check payable to UND-CRH

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