Minority Access Conference

MINORITY ACCESS' NINTH NATIONAL
ROLE MODELS CONFERENCE
SEPTEMBER 26-29, 2008
- One of the Nation's First and Most Prestigious Health Disparities Conferences -
CRYSTAL GATEWAY MARRIOTT, ARLINGTON, VA

Contact Information

Salutation: Dr.Mr.Mrs.Ms.Other

First Name:

Last Name:

Title:

Organization:

Address:

City:

State:

Zip:

Phone:

Fax:

Email:

Registration Packages

Please select appropriate package. A registration form is required for each registrant, including companion registrants.	Until May 31st	Until June 30th	Until August 31st	After August 31st
Full Conference (Conference materials, sessions, reception, meals, and banquet)	$399	$499	$599	$699
Premier Associate Student of Premier Associate Elite Associate Standard Associate	$399 (waived)	$499 (waived)	$599 (waived)	$699 (waived)
One Companion Registrant	$375	$375	$375	$400
Awards Banquet Only	$175	$175	$175	$225

Payment Method

Total Due:

Package Selected:

Please select one: VisaMaster CardAMEX

Name of Cardholder:

Card Number:

Expiration Date:

Confirm:

By checking here, I authorize Minority Access, Inc. to charge the selected registration fee to the card number supplied according to the card issuer agreement. Confirmation of your registration will be sent to you within the next 48 hours. I acknowledge that registration cancellations must be made in writing. Cancellations received by August 13 are eligible for refunds, but are subject to a $25 processing fee. Cancellations received after August 13 are ineligible for refund; however registrations are transferable to an alternate for the Eighth National Role Models Conference. (REFUNDS ARE NOT AVAILABLE FOR NO-SHOWS). If you have questions regarding your registration, please phone 301.779.7100 or e-mail ebernard@minorityaccess.org.