REGISTRATION FORM
The 5th Annual Florida Perinatal Quality Collaborative Conference
April 7-8, 2016
First:
MI:
Last:
Male
Female Birthday (mm/dd):
Academic Degree:
Email address:
Do you want your email address to appear on the participant list?
yes
No
Check here if a reasonable accommodation of a disability is requested.
Phone:
You will be contacted by conference management.
Organization:
Fax:
Address:
City, State, Zip:
If from Florida, what county:
Professional Profile:
Physician
Nurse
Community Representative
Other:
“Burning Question” I would like the faculty to address during the program:
Send questions via email to Bobbi Rose at brose@health.usf.edu
How did you hear about this conference?
Website
E-Mail
Colleague
Brochure
Other: ______
Registration Fees (US dollars):
Attendee Type
Nurse / Community Representative
Nurse / Community Representative: single day
 Thursday
 Friday
Physician
Physician: single day
 Thursday
 Friday
Discount, per person, for group of 4 or more
Early Bird:
(through March 16)
$280
Regular:
Mar 17 – Apr 3
$300
Late/On-site:
April 4-8
$320
$195
$310
$215
$335
$230
$350
$220
-$25
$240
-$25
$260
N/A
Total Due:
For payment in US dollars:
Enclosed is my check payable to USF HPCC in the amount of $
.
Mail registration form with check to:
In note field, write LK2016363/1186
USF Health Professions Conferencing Corp.
ATTN: LK2016363/1186
P.O. Box 628263
Orlando, FL 32862-8263
Fax to (813) 224-7864
Credit Card:  VISA
 American Express
 MasterCard
Card number: ______________________________________
Expiration Date: _____ / _____
Amount to be charged: $________
security digits on back: _______
Name on card: _________________________________________
Signature: _____________________________________________ Date: ____________________
Does payment reflect more than one registration?  Yes
 No
If yes, please create a registration form for each participant, but put payment information on one form
only.