Kaua‘i Youth Vaping Epidemic Conference

Kaua‘i Youth Vaping Epidemic: Help clear the cloud
Thurs, Nov 15, KCC Fine Arts Auditorium
8-11:30am

As of November 9th, this conference has reached a maximum capacity of 100 participants registered. After this date, all who register will be placed on a waitlist. We encourage all interested parties to register and we will try our best to accommodate you. We will notify you by Wednesday 4 pm if you may attend.

There will be no immediate email confirmation sent. If you prefer, you may send an email to valerie@hiphi.org to confirm your registration.

This conference is brought to you by Kauai Rural Health Association (KRHA) and the Coalition for a Tobacco-Free Hawaii (CTFH). This conference is FREE for current KRHA members and $15 for non-members. Registration is open to the first 100 people who complete this form, with priority given to current KRHA members. Payment will be collected at the event in the form of cash or check, receipts will be available at the event.

Scholarships are available on a first come first serve policy. Applicants will be notified via email by November 1st.

KRHA will send a reminder email on Friday, November 9th, if you do not receive an email then, we either didn't receive your registration or your email address was mistyped in the registration, please double check all info before submitting.

If you would like to be a KRHA member, you may email Fran Becker for an application in advance at naleiwili@gmail.com

KRHA 2018-19 dues: $25 individual, $50 business (2 employees)

Question Title

* 1. What is your FIRST and LAST name?

Question Title

* 2. Business or organization?
(If attending as a parent or student, please write "parent" or "student")

Question Title

* 3. Title?
(If attending as a parent or student, please write "self")

Question Title

* 4. E-mail

Question Title

* 5. Are you a 2018-2019 member of Kauai Rural Health Association?

Yes

Unsure (we will contact you to verify)

Question Title

* 6. This conference is free for current 2018-19 KRHA members. If you answered "no" above, do you plan on registering as a KRHA member (individual or business) at the conference to receive free registration to the event, or will you pay $15 conference fee at the door? Please select an option below:
(Receipt will be provided, cash or checks only)

I am a current 2018-19 KRHA member and understand this conference is a benefit of my membership.

Yes, I plan to register for an individual membership and will pay $25 dues at the door.

Yes, I plan to register for a business membership and will pay $50 dues at the door.

No, I do not plan to become a KRHA member and I will pay $15 at the door.

I am a parent or a student and I plan on applying for registration scholarship, however, I understand if I do not receive a scholarship, I will pay $15 at the door.

Question Title

* 7. Are you a parent of a current high school or middle school student and seek a scholarship to cover the cost of registration? Please list the name of the school(s) your child(ren) attends and the number of students in each school.

Example: Waimea Canyon Middle School (1), Kapa‘a High School (3)

*Scholarship is based on availability and on a first come first serve policy. Need and number of children do not affect priority.

Question Title

* 8. Are you a current student and seek a scholarship to cover the cost of registration? Please list the name of the school you attend.

Example: Kaua‘i High School or Kaua‘i Community College

*Scholarship is based on availability and on a first come first serve policy. Need or location of school does not affect priority.

Question Title

* 9. Are you a business/organization that would like to contribute to a resource table at this event, and you are a 2018-19 KRHA member, please enter your email address and someone will contact you by November 1st for consideration.
(Please leave blank if you don't have any resources to contribute)

Question Title

* 1. What is your FIRST and LAST name?

Question Title

* 2. Business or organization? (If attending as a parent or student, please write "parent" or "student")

Question Title

* 3. Title?(If attending as a parent or student, please write "self")

Question Title

* 4. E-mail

Question Title

* 5. Are you a 2018-2019 member of Kauai Rural Health Association?

Question Title

Question Title

Question Title

Question Title

* 9. Are you a business/organization that would like to contribute to a resource table at this event, and you are a 2018-19 KRHA member, please enter your email address and someone will contact you by November 1st for consideration.(Please leave blank if you don't have any resources to contribute)

* 2. Business or organization?
(If attending as a parent or student, please write "parent" or "student")

* 3. Title?
(If attending as a parent or student, please write "self")

* 9. Are you a business/organization that would like to contribute to a resource table at this event, and you are a 2018-19 KRHA member, please enter your email address and someone will contact you by November 1st for consideration.
(Please leave blank if you don't have any resources to contribute)