Second International Health Humanities
Conference Registration
Title (Prof., Dr., Mr., Mrs., Ms., Miss, etc.)
Last Name
First Name
Organization
Position
Address (Number, Street, Apartment Number, etc.)
Address (City, State/Province, Country, Postal Code)
Email Address
Telephone Number (Include International Exchange)
Fax Number (Include International Exchange)
Special Dietary Requirements
Access Requirements
Registration Options -- Attending FULL Conference (9, 10, 11 August)*
Professional, Payment Received On or Before 31 May 2012 ($350 US)
Professional, Payment Received After 31 May 2012 ($400 US)
Student**, Payment Received On or Before 31 May 2012 ($175 US)
Student**, Payment Received After 31 May 2012 ($200 US)
Registration Status -- Attending One Single Day of Conference
Professional, Payment Received On or Before 31 May 2012 ($200 US)
Professional, Payment Received After 31 May 2012 ($250 US)
Student**, Payment Received On or Before 31 May 2012 ($100 US)
Student**, Payment Received After 31 May 2012 ($125 US)
*Presenters Must Choose One of the FULL CONFERENCE Options
**Students Must Provide Proof of Current Student ID (Send Copy With Payment Voucher)
Please indicate whether or not you will be staying on the Montclair State University Campus and, if so, what sort of room you will require (please refer to Conference Housing information for details about on-campus and off- campus options--Please note: ALL OCCUPANTS OF ON-CAMPUS HOUSING MUST BE AT LEAST 18 YEARS OF AGE
On-Campus Housing, Single Room (Add $47 US per Registrant, per Night, Plus a One-Time, $15 US Linen Fee, to Registration Total)
On-Campus Housing, Double Room (Add $41 US per Registrant, per Evening, Plus a One-Time, $15 US Linen Fee, to Registration Total)
Off Campus Housing (Hotel or Other)
If you are staying on the Montclair State University campus, on which night(s) will you be staying?
8 August 2012 (Wednesday Evening)
9 August 2012 (Thursday Evening)
10 August 2012 (Friday Evening)
11 August 2012 (Saturday Evening)
Please indicate whether or not you will be attending the optional conference dinner on Friday evening, 10 August 2012 (please refer to Conference Dinner information for details)
Yes (Add $60 to Registration Total)
No
