Boston College School of Nursing
Preceptor Registration Form
Northeast Regional Nurse Practitioner Conference
Pre-Conference Workshops: Wed, May 4, 2016 • Conference: Thurs & Fri, May 5–6, 2016
Radisson Hotel Downtown, Manchester, NH
Please let us know which Preceptor Award you are using:
 One Day Free
 Two Days Free
I will attend (check all that apply):
 Wednesday
 Thursday
 Friday
Please Note: There is not a complimentary lunch option on Friday.
If you have registered for additional days/sessions beyond your Preceptor Award,
please complete the payment form below
__________________________________________________________________________________________
Payment must be included when submitting this registration form.
EARLY BIRD REGISTRATION:
Postmarked on or before February 26, 2016
1-day — $100
2-day — $195
GENERAL REGISTRATION:
Postmarked after February 26, 2016
1-day — $125
2-day — $220
Registration Fee
$________ (see pay table above)
Friday Breakfast Symposium Fee
$________ (add $30, if applicable)
Friday Lunch Symposium Fee
$________ (add $30, if applicable)
$________ TOTAL
PAYMENT TYPE:  MasterCard  VISA  AMEX  CHECK (payable to: Trustees of Boston College)
Card #: _________________________________________________________ Expiration Date: ________
Signature: ____________________________________________________________________________
Special Needs Request: __________________________________________________________________
Website: www.bc.edu/npconference
Email: janet.stout@bc.edu
Phone: 617-552-4257
Fax: 617-552-2121
Mail:
Boston College, William F. Connell School of Nursing, Continuing Education Program
Maloney Hall, 280, 140 Commonwealth Avenue, Chestnut Hill, MA 02467
PERSONAL INFORMATION
Name ___________________________________________________________NP  PA  RN  Other
Home Address_________________________________________________________________________________
City State Zip __________________________________________________________________________________
Day Phone _________________________________ Cell Phone _________________________________________
Employer _____________________________________________________________________________________
Email Address_________________________________________________________________________________
Specialty:
 Acute
 Geriatric
 Primary Care
 Women’s Health
 Adult
 Pediatric
 Psychiatric
 Other
SESSION CHOICES: Below, please circle which sessions you would like to attend. For the day sessions, we will try
to give you your first choice, but if the session is full or if a choice is not indicated, we will assign a session for you.
WEDNESDAY WORKSHOPS ($200 additional)
Session A —
1st Choice 1 2 3
Session B —
1st Choice 4 5 6
2nd Choice 1 2 3
2nd Choice 4 5 6
THURSDAY
Session A —
1st Choice 1 2 3 4
2nd Choice 1 2 3 4
Session B —
1st Choice 5 6 7 8
2nd Choice 5 6 7 8
Session C —
1st Choice 9 10 11 12
2nd Choice 9 10 11 12
Session D —
1st Choice 13 14 15 16
2nd Choice 13 14 15 16
I will attend Thursday Lunch
I will attend
 MCNP Association Meeting
 Reception
 NHNPA Association Meeting
FRIDAY
Session E —
1st Choice 17 18 19 20
2nd Choice 17 18 19 20
Session F —
1st Choice 21 22 23 24
2nd Choice 21 22 23 24
Session G —
1st Choice 25 26 27 28
2nd Choice 25 26 27 28
Session H —
1st Choice 29 30 31 32
2nd Choice 29 30 31 32
Optional Friday Sessions:
 Breakfast Symposium: ($30)  Lunch Symposium: ($30)