Under 100 Registration Form
Dinner served at 6:30pm
All meetings are from 7:00pm - 9:00pm
*
1.
Select the location & date of the meeting you will attend.
(Required.)
March 28 - Hot Springs
(Embassy Suites-400 Convention Blvd, Hot Springs)
April 11 - Jonesboro
(Embassy Suites-Red Wolf Convention Center- 223 Red Wolfe Blvd, Jonesboro)
April 16 - Camden
(Native Dog Brewing-125 Madison Ave, Camden)
May 7 - Mountain Home
(Big Creek Golf & Country Club Dr, Mountain Home)
August 6 - Helena
(UAMS East Regional Campus-1393 Hwy 242 S.-Helena, AR 72342
*
2.
Name (First & Last)
(Required.)
*
3.
Email address
(Required.)
*
4.
Phone Number
(Required.)
*
5.
Mailing Address
(Required.)
*
6.
Organization
(Required.)
*
7.
Degree
(Required.)
8.
Dietary Restrictions
9.
Race (Optional)
White
Black or African American
Hispanic or Latino
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Another race
