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.Name *AffiliationAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email * Sept. Method Fees 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.)Nursing Contact Hours ($15)Social Worker CEU ($15)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 InvoicePayPal Lunch and snacks will be provided. Please let us know if you have any food allergies: [email protected] Submit
