Minnesota Network of Hospice & Palliative Care

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

MNHPC is proud to partner with Holistic Underground to present "Responding to Racism in Hospice and Palliative Care"

Registration

Qty

Description

Amount

Total

MNHPC Member

$199.00

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Non-Member

$299.00

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Hospice Volunteers, Students, and Retirees

$99.00

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Discount Code

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Total: $0.00

Attendee Information

If you are registering someone other than yourself, or registering multiple people, please enter their contact information below. If you're registering more than four people, please send additional attendees information to jenna2@mnhpc.org with the subject line "Responding to Racism Session - Additional Attendee Information".

Name: *

First and Last

Email: *

Company/Agency Name:

City: *

State: *

Professional Title/Role: *

Cell Phone *

We will only use this if we need to contact attendees regarding a change to the event.

Name 2:

First and Last

Email 2:

Company/Agency Name 2:

City 2:

State 2:

Professional Title/Role 2:

Cell Phone 2

We will only use this if we need to contact attendees regarding a change to the event.

Name 3:

First and Last

Email 3:

Company/Agency Name 3:

City 3:

State 3:

Professional Title/Role 3:

Cell Phone 3

We will only use this if we need to contact attendees regarding a change to the event.

Name 4:

First and Last

Email 4:

Company/Agency Name 4:

City 4:

State 4:

Professional Title/Role 4:

Cell Phone 4

We will only use this if we need to contact attendees regarding a change to the event.

Payer Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Telephone: *

E-mail: *

A receipt will be e-mailed to this address.

Your Payment Information

Name on Card:

Card Number:

Security Code:

Expiration Date: