test 111 | Mid-Carolina AHEC

First Name *

Last Name *

Home Address *

Address (extra field)

City *

Your State of Residence *

Zip *

Email *

Phone Number *

Profession/Credentials *

Employer *

Perinatal Association Membership? *

Which days will you attend? *

One day only (Sunday, September 29) [$105.00]

One day only (Tuesday, September 27) [$105.00]

Both Days (Day 1 and Day 2) [$260.00]

Which days will you attend? *

One day only (Sunday, September 29) [$295.00]

One day only (Tuesday, September 27) [$115.00]

Both Days (Day 1 and Day 2) [$295.00]

Pre-conference Workshop (Select One) + $75 *

Pre-conference 1 [$100.00]

Pre-conference 2 [$100.00]

Supporting Our Perinatal Famiilies [$75.00]

I do not plan to attend a pre-conference workshops

Pre-conference Workshop (Select One) + $50 *

Pain Nurse Liaison Training [$50.00]

Pain Management in the Neonate/Medically fragile NICU Grad [$50.00]

Supporting Our Perinatal Famiilies [$50.00]

I do not plan to attend a pre-conference workshops

CONCURRENT SESSION A (PLEASE SELECT ONE)

1) session 01

2) session 02

3) session 03

4) session 04

CONCURRENT SESSION B (PLEASE SELECT ONE)

5) Postpartum LARC - Improving on patient-centered care

6) Breastfeeding the Tongue-Tied Baby

7) Unsafe Sleep: Case Studies from the Field

8) Evidence for a Small Baby Unit: Creating Expertise by Experience

Which Business Lunch do you plan to attend

NC

SC

I have dietary restrictions (i.e. vegetarian, gluten free, allergies)

No

Yes

I have dietary restrictions (i.e. vegetarian, gluten free, allergies) Yes

If Yes, please tell us what your dietary restrictions are.

Please indicate if you will attend the Reception

Yes

No

Event Date: