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1. Registration for 3rd North Dakota Conference on Injury Prevention and Control

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* 1. First Name

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* 2. Last Name

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* 3. Agency/Organization

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* 4. Title

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* 5. Address

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* 6. City

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* 7. State

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* 8. Zipcode

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* 9. Phone (work)

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* 10. E-mail Address

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* 11. Please Mark ALL Education/Contact Credits You Will Apply For

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* 12. Please check one answer below.

Registration fee includes one breakfast, two lunches, breaks and conference materials.

Registration is not complete until payment is received. Confirmation emails will be sent upon receipt of payment.

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* 13. Which meals will you be attending?

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* 14. Payment Method:
*We are unable to accept credit cards or purchase orders. Checks only please.
**Registration is not complete until payment is received.
***Cancellations will not be accepted or refunds issued after September 24, 2014

Please make checks payable to North Dakota Public Health Association (NDPHA)

Send to:
North Dakota Department of Health
Division of Injury Prevention and Control
600 E Boulevard Ave., Dept 301
Bismarck, ND 58505-0200


If you need assistance completing the registration or have questions, please email Missy at missykopp@nd.gov or call 701.328.4536 or 1.800.472.2286 press #1.
In an effort to be more environmentally friendly, the North Dakota Conference on Injury Prevention and Control will not be duplicating handouts for any sessions. Please print any handouts that you would like to have with you at the conference. These presentations/handouts also will be available after the conference.
<Handouts will be available after Sept. 12, 2012, on our website: www.ndhealth.gov/injury/trainings.htm. </FONT SIZEt>

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