6th Annual New England Rural Health RoundTable
Symposium:
Healthy Rural Communities Moving Forward
October 15th, 16th, and 17th, 2003
Registration Form
(Please Print off and Mail/Fax Back)

MEMBERSHIP
APPLICATION

Name

_____________________________
(please print name clearly to ensure correct spelling on name tag)

Credentials

_____________________________

Org'n

_____________________________

Address

_____________________________
_____________________________

City/Town

_____________________________

State

__________ Zip ________________

Phone (W)

_____________________________
Phone (H) _____________________________

FAX

_____________________________

Email

_____________________________

Add Addtional Two Names
if Organizational Registration

Name

_____________________________

Credentials

_____________________________

Name

_____________________________

Credentials

_____________________________
 

Membership

The current membership period for the 2003 New England Rural Health RoundTable is October 2003 to October 2004. If you are unable to attend the conference you may still join as a member.
Individual Membership Only.......$50.00
Organizational Membership Only.....$125.00

PRIMARY REGISTRANT
(please circle one)

Particpant
Weds.
Thurs. & Fri.
Weds.-Fri.

Individual

Member

Non-
member

 

$75.00

$100.00

 

$200.00

$225.00

 

$250.00

$275.00


Organization

Member

Non-
member

(includes 3
registrations
)

 

 

$210.00

$235.00

 

$585.00

$660.00

 

$735.00

$810.00

Total



Additional Registration Information
  • Add $20 per registration for those received after September 19th
  • Registration fees are non-refundable
  • A limited number of scholarships are available

Contact Carrie Todd at [email protected] or
603.895-1514 x3

MAIL OR FAX THIS COMPLETED FORM TO
NERHRT, c/o Carrie Todd
128 State Route 27
Raymond, NH 03077
FAX: 603-895-1312
Checks should be made payable to NERHRT and should include reference to attendee name(s)

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