REGISTRATION FORM Diversity Information Session Workshop  Baltimore, MD University of Maryland School of Nursing    Baltimore, Maryland Steve Alves, CRNA, PhD Place: University of Maryland School of Nursing 655 W. Lombard Street Baltimore, Maryland Date: March 27, 2010 8 am - 4 pm Guest Speaker: Steve Alves CRNA, PhD (AANA Vice President)

Registration and Hotel Information: Airport:      Baltimore Washington International (BWI) Hotel:     Residence Inn by Marriott Baltimore Downtown Inner Harbor Hotel 17 Light Street Baltimore, MD *** One Bedroom Suite -  $129 per night >> HOTEL RESERVATION LINK << (Four blocks from U of MD School of Nursing) REGISTRATION FES: RN / CRNA / Other: $175.00 Nursing Student / SRNA: $150.00 Late Fee assessed: Additional $50 after March 20th Registration Fee includes: Continental Breakfast, Buffet Luncheon and Folder filled with important information, video of minority nurse anesthesia students reviewing anesthesia machine and related equipment, and resources First Name:     Last Name:     Address 1:     Address 2: City:     State Select a State Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming     Zip       Phone:  Ex. 555-555-5555     Email:      Race  *optional   Level of Experience: Select Level Nursing Student SRNA RN CRNA Other     Payment Type: Select Payment Type Credit or Paypal Check Money Order