Conference

Registration
Pediatric Palliative Care Conference,
Friday, November 15th, 2019

Sparrow Science and Health Pavilion, East Lansing

NOTE: DETAILS ARE PROVISIONAL BUT REGISTRATIONS ARE ACCEPTED

First Name *

Last Name *

Suffix

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Occupation (if applicable)

Employer (if applicable)

If you need wheelchair access or other assistance , please state:

Please state any special dietary needs:

Are you an individual member of the Coalition or an employee of a Sustaining Member? *

Yes

No

Choose registration category *

Non-member ($125)

Member ($85)

Parent non-member ($30)

Parent member ($15)

NOTE:
Corporate members should notifiy us directly the names of their official representatives by emailing us at admin@childpalliative.org to include name, title, and email address.

Click "Continue" to proceed to payment page

(Your payment by credit card completes the registration process)