2023 Perinatal Partnership Conference Registration

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? *

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

Which days will you attend? *

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

Pre-conference Workshop (Select One) + $100 *

Pre-conference 1 [$100.00]

Pre-conference 2 [$100.00]

I do not plan to attend a pre-conference workshops

Pre-conference Workshop (Select One) + $100 *

Pre-conference 1 [$100.00]

Pre-conference 2 [$100.00]

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

CONCURRENT SESSION B (PLEASE SELECT ONE)

1) session 01

2) session 02

3) session 03

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.

Mid-Carolina AHEC