RegistrationPediatric Palliative Care Conference, Friday, November 10, 2017 (Note: To register by mail instead of online, click here to download printable form)   Please bear in mind that your entry here is also the basis for conference name tags. If you enter "Mr." under "Suffix", for example, your name will show as "John Doe, Mr."
First Name *
 
Last Name *
 
Suffix
 
Street Address *
 
Address Line 2
 
City *
 
State *
 
Zip Code *
 
Phone Number *
 
Email Address *
 
Occupation *
 
Employer (if applicable)
 
Will you need a Certificate of Continuing Education? *
 Yes
 NO
If "Yes", please state which category?
 Nursing
 Social Work
Are you an individual member of the Coalition? *
 Yes
 No
Are you the designated representative of your employer? *
 Yes
 No
Choose registration category: *
 Non-member ($125)
 Member - or Sustaining Member employee ($65)
 Family/parent member ($15)
 Family/parent non-member ($40)
 Designated representative ($0)
Click "Continue" to proceed to payment page (Your payment by credit card completes the registration process)