Howard University Hospital and College of Medicine

Name: (required)
Specify if physician:	Yes No
Mailing Address: (Required)
City:
State:
Zip:
Daytime Phone: (required)
Evening Phone:
E-mail: (required)
Parking Desired:	Pay on-site upon exiting the parking lot. ($2.00 first hour or $6.50 maximum for 5-24 hours)
Special Assistance Needed:	Hearing Vision Mobility
Check One:	Physician Clergy Nurse Social Worker Other

Quantity	Selections
	$35.00 - Celebratory Plenary
	$60.00 - Seminar Only
	$100.00 - Banquet Only
	$160.00 - Seminar and Banquet
	$45.00 - Brunch
	$200.00 - Discounted Total Package
Limited Complimentary Registrations with ID:	(First-come basis), seminar only, for: HU Health Professions Student (specify) HU Health Professions Resident HU Divinity Student
Charge My:	Visa Exp. Date M/C Exp. Date Name on Account