Event Registration

The 13th Annual Summit on HIV and Adolescents


Mashantucket Pequot Museum, Mashantucket, CT
On Friday, March 26, 2010 at 8:30 AM


First step: Please provide the information requested below, and click the "Send" button. Required fields are marked with a *.  

Name *:  
Title:
Credentials *:
Organization:
Department:
Address:
City:
State:    Zip:
Phone:
This is a: work number private number
E-mail *:
This is a: work address private address
   
Areas of interest:  Acupuncture/Complementary Therapies
 Adolescents
 Dental
 Homeless Population
 I am from a Ryan White Funded Agency
 Legal & Ethical Issues
 Managed Care
 Primary Care
 Prison Population
 Research
 Substance Use
 Women's Issues

Questions or
comments:

   

Payment:

$

If registration fee is not received by Friday, March 19, 2010, the registration will be cancelled.

 paypal ccfor credit card payments and instant bank xfer.

 Pay by check. Make checks payable to
NEAETC and send to:
23 Miner Stret
Boston MA 02215-3318

 No payment required  (This is only applicable to approved scholarships or tuition waivers)