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: email@example.com 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.