Online Registration: Child Agricultural Injury Prevention Workshop
September 17-18, 2019
Hershey Lodge in Hershey, PA

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* Name (First and Last):

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* Job Title:

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* Organization Name:

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* Mailing Address:

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* City, State/Province, Country, Postal Code:

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* Phone (Daytime):

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* Phone (Cell or Other):

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* Email Address:

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* Dietary Restrictions or Allergies:

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* I will be attending the free pre-workshop reception on September 16 (evening):

Yes

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* I will be attending the free Invest in Your Health training on September 18 (afternoon):

Yes

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* Registration:
Note: Registration fees are due 30 days prior to the workshop. A reminder will be sent two weeks prior to the due date.

$199 Early Bird Registration

$249 Registration after March 1, 2019

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* I will pay the registration fee by:

Check (make payable to Marshfield Clinic and mail to Marshfield Clinic; Conference Registration-GR; 1000 N Oak Ave; Marshfield WI 54449)

Credit Card, please call 715-389-3776 to make payment (Marshfield Clinic accepts MasterCard, VISA, American Express, Discover)

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* AgInjuryNews.org

Register me (free of charge) for AgInjuryNews.org (This website will be used/referenced during the workshop. Website registration will be helpful, but is not required)

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* Thank you for your registration. If you have any comments, please enter them below.

Click on the Submit Registration button to complete your registration.
*Please note: you will not receive a confirmation email immediately upon submitting your registration. An email confirmation will be sent within 1 week of registration.

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* Name (First and Last):

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* Job Title:

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* Organization Name:

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* Mailing Address:

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* City, State/Province, Country, Postal Code:

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* Phone (Daytime):

Question Title

* Phone (Cell or Other):

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* Email Address:

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* Dietary Restrictions or Allergies:

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* I will be attending the free pre-workshop reception on September 16 (evening):

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* I will be attending the free Invest in Your Health training on September 18 (afternoon):

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* Registration: Note: Registration fees are due 30 days prior to the workshop. A reminder will be sent two weeks prior to the due date.

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* I will pay the registration fee by:

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* AgInjuryNews.org

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* Thank you for your registration. If you have any comments, please enter them below.

* Registration:
Note: Registration fees are due 30 days prior to the workshop. A reminder will be sent two weeks prior to the due date.