2018 Heartbeat Conference Workshop Submission

Presenter Information

Question Title

* 1. Contact Information

First and Last Name: *

Organization: *

Address: *

Address 2:

City: *

State: *

Zip: *

Country: *

Email Address: *

Cell Phone Number: *

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* 2. If applicable, assistant's information:

Asst. Name:

Asst. Email Address:

Asst. Phone Number:

Question Title

* 3. Please list any credentials/professional designation (i.e, LAS, Ph.D., R.N., etc...)

Question Title

* 4. If with a pregnancy help organization, is it an affiliate of Heartbeat International?

Yes

No

N/A