North Dakota Child Passenger Safety Conference

1. First Name
2. Last Name
3. Agency/Organization
4. Title
5. Address
6. City
7. State
8. Zip Code
9. Email Address
10. Work Phone Number
11. Cell Phone Number
12. The registration fee (before September 17, 2013) is $60.00 and includes 2 breakfasts, 2 lunches, breaks and conference materials.

The registration fee (if postmarked after September 17, 2013) is $100.00

Refunds will not be issued after September 17, 2013.

Please mark which meals you will be attending:
Credit card payment is not available for this conference. Please print the confirmation page for this registration and return it with your check payable to the North Dakota Public Health Association (NDPHA) to the North Dakota Department of Health address listed below. Registration is not complete until payment is received.


Send registration confirmation and check to:
North Dakota Department of Health
Child Passenger Safety Program
600 E. Boulevard Ave., Dept. 301
Bismarck, ND 58505-0200

Phone: 701.328.4533 or 800.472.2286 press 1
Fax: 701.328.1412
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