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					                                                                                    We will be creating an MPH Class of
                                                                                    1992/Caribbean Alumni Directory.
                                                                                    Check this box to opt-out.
Alumni Reunion
Baltimore, July 19-20, 2012
St. Lucia, July 30-August 2, 2012
Registration Form
Name:

Street Address:

City/Town:

State/Province/County:

Zip/Postal Code &
Country:
Telephone:

E mail address:


Occupation: __________________________             Employer: _____________________________________
I would like to attend:

        Baltimore Reunion, July 19-20 ($75)
        *Guest cost: $50 (children under 15 free)          Name of guest(s): _____________________________

        St. Lucia Reunion, July 30-August 2 (NO FEE)
        *Guests pay on site                        Name of guest(s): _____________________________
Names of faculty with whom you would like to reconnect (Baltimore only):
___________________________________________________________________________________

Payment Information               Total Amount enclosed / to be charged to card. $ _____________

      My check/money order payment is enclosed. Checks/money orders are payable to The Johns Hopkins University.

      I would like to pay by credit card.

Credit Card:      DISCOVER _____                   VISA _____               MASTERCARD _____

Cardholder’s Name __________________________________ Card No. ___________________________________

Cardholder’s Signature _______________________________              Expiration Date _____________________________

Cardholder’s Phone Number __________________________

Cardholder’s Billing Address _____________________________________________________________________

City/State/Zip: __________________________________________________________________________________

 Mail or fax form to: Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Suite E2148, Baltimore, MD 21205.
                  Fax: (410) 614-2405. The deadline for registration is July 13, 2012 and no fees will be refunded.
      Questions? Contact Philippa Moore, Director of Alumni Relations at 410-614-5019 or by e mail at pmoore@jhsph.edu

				
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posted:9/17/2012
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