Wednesday, November 14, 2012
University of Maryland School of Nursing
655 W. Lombard St., Baltimore, MD 21201
Conference Registration Form
Type or Print
First Name Middle Initial Last Name
City State ZIP Code
Home Phone Work Phone
Check one or more, if applicable.
Health Care Employee
Vendor (not exhibiting)
UM Faculty or Staff
Other - Please Specify: ___________________________________________
How did you hear about this program? Please check all that apply.
Email Website Colleague Other: _____________
Environmental Excellence in Health Care - November 14, 2012
Executive Breakfast ONLY FREE
Executive Breakfast & Conference $55
Individual Registration (postmarked on or before October 22) $55
Registration (October 22-November 7*) $65
Student Rate $25
Exhibitor Registration $325
Sponsorship (For details contact Joan Plisko, 410-706-2107, or firstname.lastname@example.org.)
*Registration is $80 after November 7 and will be accepted onsite only.
Additional fee for Continuing Nursing Education $30
TOTAL PAYMENT: __________
Check #_______ enclosed (made payable to: University of Maryland School of Nursing)
Purchase Order # ________________ Enclose a copy of P.O.
VISA American Express MasterCard
Account Number _________________________________ Exp. ___________________
Name on Credit Card ______________________________________________________
Authorizing Signature _____________________________________________________
Mail or fax this form with payment to: University of Maryland School of Nursing, Office of
Professional Education, 655 W. Lombard St., Room 311G, Baltimore, MD 21201-1579
Special Requests: If you need special assistance, contact the Office of Professional Education at
410-706-3767 or email@example.com.
Photography: The University of Maryland School of Nursing has arranged for a photographer to
be present throughout the conference. We may use these photographs to publicize the event or
UMSON, or to produce related literature and products for public release. Participants who are
opposed to being photographed must notify the photographer or conference staff if their picture is
Participant List: Please check here if you DO NOT want your contact information to be
included in the participant list shared with exhibitors.
Refund Policy: Requests for refunds must be received by 5 p.m. Monday, October 22, 2012.
For Information: Call 410-706-3767, email firstname.lastname@example.org, or visit
To decrease the carbon footprint of this conference, we encourage you to use public transportation to and from the