The Alexis Foundation/Preemie-l Conference Registration Form

Registration for the The Alexis Foundation/Preemie-l Conference July 30-31, 1999

Please print out the page below, fill in your details, attach a check or money order for the appropriate amount, and mail to:

NAME: _____________________________HOSPITAL/BUSINESS:________________________________

CITY:____________________________STATE:______________________________ZIP:______________

PHONE:________________________FAX:______________________EMAIL:_______________________

**Conference rates include conference only. Hotel & meals not included.

(Please check one) PARENT: $125 _____ PROFESSIONAL: $150 _____
Please note: If you attended last year's conference you are eligible for a $15 discount on this year's fee.

(NURSES): WILL YOU BE REQUESTING CONTINUING EDUCATION CREDITS? Y _____ N _____

**We will be applying for continuing education credits for nurses through the Michigan Nurses Association. Please contact us for more information.

LUNCH (Optional): FRIDAY: $15 _____ SATURDAY: $15 _____ BOTH DAYS: $30 _____

If you have any special dietary requirements, please let us know________________

________________________________________________________________________________________

Please call the Radisson Hotel, Schaumberg on (847) 397-1500 to make reservations. State that you are with The Alexis Foundation Conference when you call. Room tax is 10% of the total bill. We have reserved a block of rooms at the following conference rates:

SINGLE ROOM - $72/Night, DOUBLE ROOM - $82/Night *Be sure to reserve your room as soon as possible as these accommodations are offered on a first come, first serve basis. Reservations need to be secured by July 1, 1999.

WILL YOU BE ATTENDING THE ALEXIS FOUNDATION FUNDRAISING DINNER? _____YES _____NO

(If yes, please include the ticket price with your conference payment)

WOULD YOU LIKE TO CONTRIBUTE TO OUR PARENT SCHOLARSHIP FUND TO ASSIST PARENTS WITH THE COST OF ATTENDING OUR CONFERENCE?

DONATION AMOUNT: $__________ (All donations are tax deductible and greatly appreciated)

PLEASE CALCULATE YOUR TOTAL CONFERENCE PAYMENT BELOW:

Conference Fee (less discount for attending last year's conference, if appropriate): _______________
Lunch: _______________

Please make check or money order payable to The Alexis Foundation, and mail completed registration form and payment to: