The Sixth Annual Chronic Illness Initiative Symposium Registration

Instructions

Thank you for your interest in attending. By registering you will be added to our email list. Watch your mailbox for important details we will be sending you over the next few months.

Registration

I would like to register for the 2010 Symposium:

*First Name:

*Last Name:

*Email Address:

Please send me text-only emails:

text only

*My affiliation is (Please check all that apply):

Publications/Media
Medical/Mental Health
College Faculty/Staff
College Student
Secondary School Faculty/Staff
Secondary School Student/Family Member
Business/Commerce
Government
Other

Other (please specify):

Registration Fee (Lunch Included)

Please enter your credit card information for the registration fee of $25.00 (which includes lunch and reception) or print the form and mail it with your check to the address below. The fee for students is $10.00. The fee is waived for symposium presenters and volunteers. We also offer hardship waivers. Please request one from Lynn Royster at lroyster@depaul.edu or 312-362-5079.

Please make check payable to DePaul University and send it to:
DePaul University
Chronic Illness Initiative
c/o Paula Kravitz, Assistant Director
25 E. Jackson Blvd, Suite 200
Chicago, IL 60604

Or fill it out and fax it to: 312.362.8152

Credit Card Authorization (This form of payment is acceptable by mail or fax only):

I authorize DePaul University's Chronic Illness Initiative to charge my credit card for the $25 registration fee.

Type of Card (Mastercard, Visa, Discover and American Express): _______
Inter bank number (for Mastercard only): ___________
Credit Card #: _____-_____-_____-_____
Expiration Date: _____/20____
Name as it appears on card: _____________________
Signature: ___________________________________
Amount: ____________

Thank You!

Thank you for registering for the 2010 Symposium.

Questions? Please contact Annie Nihls at anihls@depaul.edu or 312.362.5079.

( * = required field )