SurveyMonkey Powered Online Survey

This course is held "live" online from 1:00 - 5:00 pm on Thursday and Friday.

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* 1. First Name (as it appears on your license if applicable)

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* 2. Last Name (as it appears on your license if applicable)

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* 3. Email Address

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* 4. County of Residence

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* 5. Kansas Nursing License # (if applicable, for RNs, APRNs, LPNs)

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* 6. Kansas Dietitian License Number # (if applicable)

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* 7. Notes (registration transfer, complimentary registration, etc.)

Acknowledgements:

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* 8. By checking this box, I authorize the Kansas Breastfeeding Coalition to photograph/video myself and/or my child (children) during this event. I hereby acknowledge that these photographs/videos may be used for the purpose of education and the promotion of breastfeeding. This authority specifically includes incorporating these photographs, videos, or replicas thereof in any material, including a website or online course. I acknowledge that these images will not be used for any commercial purpose.

Yes

No

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* 9. I understand that registrations canceled on or before 10 days prior to the event date are refundable but subject to a $10 administrative fee. Registrants canceling less than 10 days prior to the event will not receive a refund. The refund and cancellation policy will not be waived.

Yes

No