Personal Information

Name

Service

Address

City

State

Zip

Day Phone

Cell Phone

State License #

State License State

Would you like an email confirming your registration? YesNo
Email:

Would you like an email copy of your receipt? YesNo
Email:

Would you like to be contacted regarding special dietary needs? YesNo
Email:

Conference Fees

One Day

FridaySaturday

$95.00 – Prior to September 23 (In region)$105.00 – Prior to September 23 (Out of region)$125.00 – After September 23 (In region)$135.00 – After September 23 (Out of region)

Two Days

$145.00 – Prior to September 23 (In region)$165.00 – Prior to September 23 (Out of region)$175.00 – After September 23 (In region)$195.00 – After September 23 (Out of region)

Would you like to attend one of the simulations on Saturday?

Labor & Delivery Post Partum HemorrhageThe Pediatric Motor Vehicle Collision “Flying Child”

Payment

Please mail cash or check to: Greater NW EMS, 2301 Johanneson Dr NW, Bemidji, MN 56601 OR call 218-556-5137 with your credit card information.

Payments received after September 23 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.