Registration Form Name_________________________________________________________________________________ Address _____________________________________________________________________________ City, State, Zip County Email Address Phone Faith  community nurse health minister/promoter leader Position / Title (please check all (please describe) that apply) _______________________________________________________________________ Organization  Please check here if you are: A new member in 2017 first time conference attendee Special diet or mobility needs Conference Options (Choose one) Member Non-member Lodging (Single room) 2 nights, 5 meals, registration $371.00 $406.00   Lodging (Double room) 2 nights, 5 meals, registration $295.00 $330.00   No lodging, 5 meals, registration $140.00 $175.00  Annual membership fee (optional) $25.00 Total amount due $ Roommate Name Send checks payable to CHMP by mail or pay by credit card at All registration forms must be received by mail to the address listed below by October 10th. Cancellation policy Mail registration form and/or payment Conference registrants cancelling their registration to Carolinas Health Ministry Partnership after Oct. 14th will receive a refund minus a $50 c/o Lelia Moore (Cone CN Program) administrative fee. If you cannot attend and would like to send a substitute, please notify Lelia Moore at 336-908-4119 within 24 hours of conference.
Registration Form Name_________________________________________________________________________________ Address _____________________________________________________________________________ City, State, Zip County Email Address Phone Position / Title (please check all that apply) Faith community nurse health minister/promoter leader (please describe) _______________________________________________________________________ Organization Please check here if you are: new member in 2017 first time conference attendee Special diet or mobility needs Conference Options (Choose one) Member Non-member Lodging (Single room) 2 nights, 5 meals, registration  $371.00  $406.00 Lodging (Double room) 2 nights, 5 meals, registration  $295.00  $330.00 No lodging, 5 meals, registration  $140.00  $175.00 Annual membership fee (optional)  $25.00 Roommate Name Total amount due $ Send checks payable to CHMP by mail or pay by credit card at All registration forms must be received by mail to the address listed below by October 10th. Mail registration form and/or payment to Carolinas Health Ministry Partnership c/o Lelia Moore (Cone CN Program) Cancellation policy Conference registrants cancelling their registration after Oct. 14th will receive a refund minus a $50 administrative fee. If you cannot attend and would like to send a substitute, please notify Lelia Moore at 336-908-4119 within 24 hours of conference. A