TRANSPORTATION INFO

The 10th National Conference on Immunization and Health Coalitions

May 23-25, 2012

REGISTRATION FORM

To register for the NCIHC conference online, please complete this form. Once the form is filled out an submitted you will be able to pay through Pay-Pal. If you have any questions please contact Gina Deris @ 504-838-5300 or gina.deris@la.gov. *required field

*Name:

Organization:

Address:

City:

State:

Zip:

Phone:

Fax:

Email:

Special Dietary Needs:

Other Special Needs:

Days of Attendance:

Pre Conference Session on Wednesday, May 23rd**: $50.00

	INNOVATION AND NEW ENERGY FOR YOUR COALITION - Fran Butterfoss
	MEDIA WORKSHOP - Tim Church, Michelle Basket, Glen Nowack

To attend all three days:

Early Registration (October 17th-February 24th): $260.00

Regular Registration* (February 11th-May 23rd): $300.00

*Payment must be received between February 11th and May 23rd to ensure the regular registration cost.

On-Site Registration**: $350.00

**The cost of registration does not include the Pre-Conference Session

To attend one day only:

Wednesday, May 23rd: $100.00 (includes reception)

Thursday, May 24th: $200.00

Friday, May 25th: $75.00

Cancellation Policy
Registrants were informed at time of registration that “partial refunds” would be available for cancellations done after Friday, April 20, 2012. The following is a table outlining those refunds.

DATES	REFUND POLICY
Saturday, April 21st –Monday, April 30th	A $25.00 processing fee will be deducted from each registration refund.
Tuesday, May 1st – Tuesday, May 15th	50% of the registration fee will be reimbursed.
After May 15th	Registration fees will not be reimbursed.

	Hosted by:
The 10th National Conference on Immunization and Health Coalitions Hosted by the Louisiana Shots for Tots Coalition, Inc. Tele: 504-838-5300 Fax: 504-838-5206