Innovations in Faith-Based Nursing Registration Form

First Name: Last Name:

Address:

City: State: Zip:

Phone: Email:

Special Needs (and Dietary concerns, Accessible accomodations needed, etc):

Type of Registration:

	Registration, Room and Board -- $500
	Full Conference Registration Only -- $250
	One-Day Registration -- $100
	Family Member (Room/Board Only, conference not included) -- $250
	Children 5-12 (Room/Board Only, conference not included) -- $100
	Children 4 and under -- Free of charge

Method of Payment: