13th Annual "Shots for Tots" Conference Registration
December 16 & 17, 2004

__________________________________________________________________
Full name (please print clearly)

__________________________________________________________________ Organization or Affiliation

__________________________________________________________________ Address                                    City                           State                                  Zip

__________________________________________________________________ Business Phone                                   Fax                                Email Address

MAIL REGISTRATION TO:
 Gina Deris     
Immunization Program    
4747 Earhart Boulevard  Suite 107
New Orleans LA 70125
 
Make Checks Payable To:
North Louisiana AHEC          

REGISTRATION FEE: $35.00
Postmarked before November 1, 2004
No refunds or credits            

LATE REGISTRATION: $50.00:
Postmarked before Dec. 1, 2004
No refund

After 12/1 and ONSITE REGISTRATION: $75.00
No refund

Astor Crowne Plaza Hotel
739 Canal at Bourbon Street, New Orleans, Louisiana 70130

Conference participants are responsible for their own hotel reservations.  Please call the Astor Crowne Plaza Reservations Department at 888-696-4806 and identify yourself with "Shots for Tots" to receive the special rate .

Rooms at SFT rate will only be guaranteed available until November 15, 2004.

Icebreaker and Silent Auction  
5:00 p.m., December 16, 2004

Nursing Continuing Education credits applied for with the Louisiana State Nurses Association which is accredited as an Approver of Continuing Education in Nursing by the American Nurses Credentialing Center Commission on Accreditation.