Contact Information
Last Name:
First Name:
Practice Name or Affiliation:
Address:
City:
State:
Zip:
Primary Phone Number:
Primary Email:
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Credentials
MD	DO	ND	Lac
DC	NP/APN	RN AHNA Code?	Midwife
Psychologist	Homeopath	Dietician	Nutritionist
Herbalist	Doula	Social Worker	Clergy
Educator	Lactation Consultant	Massage Therapist
Other
Licensed?	Non-Licensed?

Residents & Students
School Attending:
Please upload your letter of status:
Residency Program:
Networking Info
Do you want your name, contact information and email address to be on the roster, which will be given to all attendees for networking purposes?
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Payment Information
	Early Bird Rate	After October 1
MD/DO:	$550	$650
ND/Chiro/Psychologist/Acu-TCM/Homeopath:	$500	$600
Nurses, Educators and Other Allied Health:	$400	$500
Residents & Students:	$200	$300

NOTE: When you click submit, this website will open PayPal in a popup window, where you will complete your registration.