Dakota Conference on Rural and Public Health

2016 Registration

Register below, or use this printable registration form.
Deadline to register online: Noon, May 10, 2016.
* 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:
Monday, May 16
Lunch
PM Break
Reception
Tuesday, May 17
Breakfast
AM Break
Lunch
PM Break
Wednesday, May 18
Breakfast
AM Break

Registration Fees
Registration forms AND payment must be received by
April 15, 2016 to receive the discounted registration.
    Registration
Full Conference Registration $275
Presenter Registration $250
One Day Only, Specify which day:  
Monday Only $200
Tuesday Only $200
Wednesday Only $150
Student Registration
To qualify as a student, you must be registered as a full-time student.
$75
Not attending the conference $0

Banquet Tickets - evening of May 17
 
Ticket for registrant $25
  Additional Tickets   # of tickets $30
  Child (12 & Under) Banquet Tickets - chicken strip meal
   # of tickets
$15

Pre/Post Conferences
Critical Access Hospital (CAH) Workshop (May 16, 2016; 8:00am–11:30pm)
     Cost is $15 each. # attending
North Dakota Public Health Association Meeting - no charge
May 16, 2016; 8:00am–11:30am
North Dakota Rural Health Association Meeting - no charge
May 17, 2016; 12:30pm–2:00pm
Grant Writing Workshop (hosted by the CRH)
No charge, must pre-register
May 18, 2016; 1:00pm–5:00pm

Please provide a written request for any special needs (including dietary):

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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