Conference Form Personal Information Name Service Address City State Zip Day Phone Cell Phone Would you like an email confirming your registration? Yes No Email: Would you like an email copy of your receipt? Yes No Email: Conference Fees One Day Friday Saturday $58.00 – Prior to September 16 ~ In region $68.00 – Prior to September 16 ~ Out of region $88.00 – After September 16 ~ In region $98.00 – After September 16 ~ Out of region Two Days $100.00 – Prior to September 16 ~ In region $120.00 – Prior to September 16 ~ Out of region $130.00 – After September 16 ~ In region $150.00 – After September 16 ~ Out of region Sessions Which sessions are you most likely to attend; note, you will be able to choose either session upon arrival. This information will be utilized for planning purposes only. Friday Session Patient Assessment Drugs, Demons & Death Session Pediatric Problems Dead or Not Dead Session Head & Facial Trauma Kids Bounce Back Session Gender & Heart Disease Returning to Work Saturday Session Cold Weather Emergencies ECMO Session Geriatric Emergencies Capnography & Airways Session Abdominal Emergencies Hemorrhage Control Session EMS Myths & Legends Regrets & Forgiveness Payment Please mail cash or check to: Greater NW EMS, 2300 24th St NW, Suite 103, Bemidji, MN 56601 OR call 218-556-5137 with your credit card information. Payments received after September 18 will be assessed the $30 late fee, even if the registration form has been received! How will you be paying?Mailing Cash/CheckCredit Card Over PhonePurchase Order Please enter your PO number if paying through purchase order.