Attendee Registration Form Annual Conference 2025 Registration Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. (Please please note Name *AffiliationAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Please check off which of the following events you plan to attend:Thursday, Sept. 18, 2025 EventsWorkshop: Grassroots Healthcare Advocacy: Why, How, When (1:00 p.m. - 4:00 p.m.)Social Time/snacks (5:00 p.m. - 5:30 p.m.)Viewing of Stan Brock’s Medicine Man film (Includes panel discussion post-film featuring) (5:30 p.m. - 8:15 p.m.)Friday, Sept. 19, 2025 Events (9:00 a.m. - 4:00 p.m.) In-person fees (Please indicate which category)Attendee (in-person) – $100UT Chattanooga staff/faculty – $50Student – $25Virtual FeesAttendee – $50UT Chattanooga staff/faculty – $50Student – $25Continuing Education Add-onsNursing Contact Hours ($15)Social Worker CEU ($15)Method of Payment *Check EnclosedPlease InvoicePayPalIf you have any food allergies or dietary preferences, please make note here.Submit
