Registration Form

21st Annual Celebration of Nursing Excellence
Registration information
Print this page and send registration and payment to:
St. Mary's Hospital
Attn: Mary Jane Schroeder
1800 E. Lake Shore Dr.
Decatur, IL 62522
Payment is $25.00 per person and must accompany registration (including group registrations)
Please make checks payable to: Decatur Area Nursing Task Force
do not send cash

Reservations must be postmarked by May 1, 2008

Individual
Name______________________________

Address____________________________

__________________________________

Phone_____________________________

Job title:

__________________________________

__________________________________

If you have special dietary needs or physical needs, please indicate below:

___________________________________

Group
Maximum of eight persons per table
Group contact person and phone:

_________________________

_________________________

List of names, job titles for group:
1. __________________________________

2. __________________________________

3. __________________________________

4. __________________________________

5. __________________________________

6. __________________________________

7. __________________________________

8. __________________________________