REGISTRATION FORM Diversity Information Session Workshop  Durham, NC Duke University School of Nursing  -  Durham, NC Terry Wicks CRNA, MHS Place: Duke University School of Nursing  307 Trent Drive Durham, NC. Date: October 23, 2010 Guest Speaker: Terry Wicks CRNA, MHS (Past President AANA)

Registration and Hotel Information: Airport:      Raleigh-Durham - RDU Hotel:     SpringHill Suites Durham Chapel Hill 5310 McFarland Drive Durham, North Carolina 27707 USA *** One Bedroom Suite -  $79 per night >> HOTEL RESERVATION LINK << REGISTRATION FES: RN / CRNA / Other: $200.00 Nursing Student / SRNA: $150.00 Late Fee assessed: Additional $50 after October 1, 2010 NOTES:  A minibus will be available (October 23, 2010) for pick up from the hotel between 7AM - 7:30AM to Duke University School of Nursing. It will depart Duke University School of Nursing at 5PM to return to SpringHill Suites - Marriott Hotel. The fee is $20 per person by check or money order, by September 15th, payable to: Diversity in Nurse Anesthesia PO BOX 202 Mickleton, NJ 08056. 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  *** Parking garage across the street*** 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