RegistrationThe Annual Fall National School Nursing Conference and Retreat Tour

Registration Form

NCEHS
14439 N.W. Military highway, #108, PMB 615 San Antonio, TX 78231

Please check date of course you wish to attend

Birmingham, AL	Sept 20, 2001	Sept. 21, 2001
Nashville, TN	Sept. 27, 2001	Sept. 28, 2001
Louisville, KY	Sept. 13, 2001	Sept. 14, 2001
Jackson, MS	Sept. 18, 2001	Sept. 19, 2001
New Orleans, LA	Sept. 25, 2001	Sept. 26, 2001
Phoenix, AZ	Oct. 4, 2001	Oct. 5, 2001
Las Vegas, NV	Oct. 6, 2001	Oct. 7, 2001
Santa Fe, NM	Oct 9, 2001	Oct. 10, 2001
Portland, OR	Oct. 18, 2001	Oct. 19, 2001
Bismarck, ND	Oct. 29, 2001	Oct. 30, 2001
Kansas City, MO	Nov. 1, 2001	Nov. 2, 2001

Rates are based on date of receipt via email, date of envelope postmarks with registration forms and money, or date of receipt via fax.

Please check appropriate rate below:

REGISTRATION FEES:

$97 per person/per day (three or more) group rate to 9/10/01. Same registration form

$117 per person/per day to 9/10/01 by date of receipt of completed form

$137 per person/per day 9/11/01 - 9/18/01 by date of receipt of completed form

$157 per person/per day 9/19/01 - 9/26/01 by date of receipt of completed form

$177 per person/per day 9/27/01 - 10/04/01 by date of receipt of completed form

$197 per person/per day after 10/04/01 by date of receipt of completed form and at the
door.

Please Fill Out Information Below:

First Name:

Last Name:

If Two Or More, List Names:

SS# For Contact Hour Record:

Agency:

Address:

City:,

(E-Mail):

H) Phone:

(F) Phone:

(W) Phone:

Title:

RN LVN Aide Soc. Worker Other

Credit Card

Account Number:Exp. Date

Cardholder Name:

(Make sure you enclose your check or credit card information)