SUMMER INSTITUTE IN NURSING INFORMATICS 2004

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					                      SUMMER INSTITUTE IN NURSING INFORMATICS (SINI) 2010
                                      Registration Form

Please type or print.
________________________________________________________________________
First Name                              Last Name
________________________________________________________________________
Preferred Mailing Address
________________________________________________________________________
City                                   State                   ZIP Code
________________________________________________________________________
Company Name
________________________________________________________________________
Home Phone                             Work Phone
________________________________________________________________________
E-mail                                 Fax

Check one or more, if applicable.
    I am a SINI invited speaker
    I am a SINI Planning Committee member
    I am a peer-reviewed paper presenter
    I am a peer-reviewed paper presenter with a SINI 2010 Scholarship
    I am a peer-reviewed poster presenter
    I am a peer-reviewed poster presenter with a SINI 2010 Scholarship
    I am a UMB faculty member
    I am a UMB full-time student
    I am a UMB staff member
    I am a UMSON alumni
    I am a student volunteer
    I am a representative of a sponsoring corporation
    I am a representative of an exhibiting corporation

How did you hear about this program? Check all that apply.
    Save the Date card       E-mail              SINI Web site
    Brochure                 Colleague           Other________________________

SINI 2010 - July 21, 22, 23, and 24
             SINI registration (postmarked on or before 7/1/10)                         $625
             SINI late and on-site registration (postmarked after 7/1/10)               $675
             SINI one-day
                Indicate day: _ Wed _Thurs _ Fri                                         $325
             UMB faculty, staff, and full-time students*                                $225
             UMB faculty and full-time students* (one-day)
                Indicate day: _ Wed _ Thurs _ Fri                                        $100
             UMSON alumni (postmarked on or before 7/1/10)                              $525
             UMSON alumni (postmarked after 7/1/10)                                     $575
             Peer-reviewed poster and paper presenters                                  $325
             Peer-reviewed poster and paper presenters (one-day)                        $195
             Representative of sponsors and exhibitors one-day (per person)             $225

                               *Students must present student ID at check-in

            A discount is available for groups of five or more representing the same organization.
                  For details, contact the Office of Professional Education at 410-706-3767.
Webcast Fees (per person) Contact us for group discounts.
           Webcast postmarked on or before 7/1/10                                 $295
           Webcast postmarked after 7/1/10                                        $350


Preconference Tutorials
              Preconference 1: Weekend Immersion in Nursing Informatics (WINI)
           WINI postmarked on or before 7/1/10                        $600
           WINI postmarked after 7/1/10                               $650

                Preconference 2: Health Care IT Project Management
               Project Management postmarked on or before 7/1/10                  $600
                Project Management postmarked after 7/1/10                         $650

                                 TOTAL PAYMENT ENCLOSED:                           ____________

Payment Method
    Check #_______ enclosed (Made payable to: University of Maryland School of Nursing)
    Purchase Order # ________________. Please enclose a copy of P.O.
    VISA
    MasterCard
    Discover
   (We do not accept American Express.)

Account Number _________________________________ Exp. ___________________

Name on Credit Card ______________________________________________________

Authorizing Signature _____________________________________________________

Fax or mail this form with payment to:
University of Maryland School of Nursing
Office of Professional Education
655 West Lombard Street, Room 311U
Baltimore, MD 21201-1579         Phone: 410-706-3767      Fax: 410-706-5560
For information: pe@son.umaryland.edu

Preferred Concurrent Sessions- To be announced
Please check preferences for concurrent sessions and plan to attend those sessions to allow for accurate
assignment of rooms.

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 the School, 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 taken.

Participant List
     Please check here if you do NOT want your contact information to be included in the participant list
        shared with vendors and other participants.

Special Requests
Contact our office if you are in need of special assistance or have specific dietary needs.

Refund Policy
Cancellations received by 7/1/10 will receive a full refund less $100 processing fee. Request for cancellations
after 7/1/10 will not be honored.

				
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