Winston-Salem State University
Center of Excellence for the Elimination of Health Disparities
School of Health Sciences
(Only return registration form if paying by check or PO)
Community Conference: Sustaining and Strengthening Communities to Improve
Health Outcomes
Thursday, September 17, 2015
The Millennium Center
101 West 5th Street
Winston -Salem, NC 27101
Paying by Check or PO Register Here
PARTICIPANT INFORMATION
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MAILING ADDRESS: ____________________________________________________________________
CITY: ________________________________ STATE: _____________ Zip CODE: ____________________
EMAIL: ____________________________________ TELEPHONE: (
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REGISTRATION FEE:
PAYMENT METHOD:
General Price $125.00
Student Price $75.00
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P.O. # __________________
Click Here to Pay On-line with Credit Card
IF PAYING BY CHECK, MAKE CHECK PAYABLE TO:
WSSU CEEHD
MAIL, FAX, OR E-MAIL REGISTRATION FORM TO:
LESLIE GAYNOR, PROGRAM DIRECTOR
WINSTON-SALEM STATE UNIVERSITY
CEEHD, FL ATKINS ANNEX, ROOM 125
WINSTON-SALEM, NC 27110
TELEPHONE: 336.750.8363
Special dietary needs or preferences:
FAX: 336.750.8385
E-MAIL: gaynorl@wssu.edu
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