2012 IRIS Advocate Training Conference Registration

You must fill out this form and complete the payment process to enroll in the 2012 IRIS Advocate Training Conference.

First Name:
Last Name:
Middle Initial:
Address 1:
Address 2:
City:
State:
ZIP:
Phone:
Cell Phone:
Email:
Organization/Hospital/Business Name:
Address 1:
Address 2:
City:
State:
ZIP:
Special dietary or physical needs:
Hotel room:
Hotel roommate name (if double occupancy room):
How did you hear about the conference?

Conference Registration:	$445.00
Hotel Reservation ($80/night):	$160.00
Total:	$605.00

(507) 334-4748