2014 WHPRMS Annual Conference Registration Form 2014 WHPRMS Annual Conference Registration Form Member Status*WHPRMS MemberNot a member of WHPRMSIf you are interested in becoming a member of WHPRMS for $100, go to: http://whprms.org/membership-application/.Option*Full conference: $295Thursday only: $220Thursday evening only: $95I will not be attending the conference:$0Will you be attending the Pre-Conference Workshop? Yes I will be attending. If yes, + $95.00 (optional)Option*Non-member full conference: $450Is this your first time attending the WHPRMS conference?YesNoOrganization Name*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name* First Last Title*Email* Phone*Will you be attending the Wednesday networking activity? (6:30 - 9:30pm) Yes, I will be participating Any food allergies we need to be aware of?Will you be attending Thursday evening's dinner?*YesNoPlease select one of three menu options*Roast Pork TenderloinGrilled SalmonGourmet Stuffed Pasta (squash served in a brown butter sauce)Will you be participating in the golf outing? Yes I will be participating. If yes, + $64.00, Wild Rock Golf Club - Wednesday morning (optional)Total $0.00 Payment Method*PayPalPay by checkPlease send payment to: UW Health Attn: Nicole Barreau 301 S. Westfield Rd., Suite 250 Madison, WI 53717Please send payment to: McDaniels Marketing Attn: Randy McDaniels 11 Olt Ave. Pekin, IL 61554EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.