Conference Registration Form



MAHA        March 19,  2010

Name___________________________

Address_________________________

_________________________

City____________________________

State_______       Zip Code_________


Employer________________________


Title  ___________________________



Email ____________________



Phone #___________________


Mail by: March 10, 2010


2010 Spring Conference Registration
                www.mimaha.com
   

Mail to: Mrs. Cynthia L. Graff
    11139 Sand Crane
     South Lyon, MI   48178-8520


Make Checks payable to: M.A.H.A.

Member                        $95.00      ___

Non-member                $150.00    ___

1st time Attendee        $50.00      ___

Retiree                          $50.00     ___

Amount Enclosed: $ _________



For registration after March 10
call Donna Bauby
at 517-861-7314
or email dbauby@asugroup.com
To register, please  "Print Page" and fill out the following form:

     This activity has been submitted to the Illinois Nurses Association Approval Unit for approval to award
contact hours. Illinois Nurses Association is accredited as an approver unit of continuing nursing education
by the American Nurses Credentialing Center’s Commission on Accreditation.
 
     As required by the American Nurses Credentialing Center’s Accreditation Program, we would like to
make you aware of all potential conflicts of interest(s).  This educational activity’s planners and the
presenter(s) have indicated they have no bias or conflict of interest.


---------------------------------------------------------------------------------------------------------------------------------------------------------------------


Cancellation policy:
Registration fee less $10 fee refundable if notice is given by 7 days before the scheduled conference.
No refund will be issued after that time.       Registrants may send an alternate.