KIM: Kids In Motion

NICU Pre-Conference: Attendee Registration

Please fill in the information below. Required fields are noted with an asterisk (*).

Personal Information

First Name: *	Last Name: *
Title:	Organization:

Address Information

Check here if this information is to remain private:
Street Address: *
City: *	State (or Province): *
ZIP: *	eMail: *
Phone: *
Special Dietary Needs:

Payment Information

$175 by May 1st, then $250 by July 1st, and finally $300 after July 1st, if you also attend the KIM conference.
$225 by May 1st, then $250 by July 1st, and finally $300 after July 1st, if you are not attending the KIM conference.
How will you be paying? *
Purchase Order #:
Make checks payable to: KIDZ IN MOTION, INC. 5424 Conway Pointe Court Orlando, FL 32812	Or (via PayPal):

Registration is NOT complete until payment has been made.

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