PRINTABLE REGISTRATION FORM - "SPRANS Regional Pre-Application Workshop"

Print and Fax to HSR, Inc. Attn: Mike Hess at 202-728-9469

"SPRANS Community-Based Abstinence Education
Regional Pre-Application Workshops"

Registration Form

Required fields are indicated with asterisks (*) (if you do not have any information to enter into a required field, just write "NA"). We ask that you please do not use any acronyms when filling out the registration form. Please check to make sure that your e-mail address is entered correctly. When complete, please fax to (202) 728-9469, Attn: Mike Hess; or call Health Systems Research at (202) 828-5100.

Please indicate below which workshop you are registering for:

Check One	Location	Date	Registration Deadline
	Kansas Ciy, Missouri	December 2, 2002	November 25, 2002
	Denver, Colorado	December 3, 2002	November 26, 2002
	San Diego, California	December 9, 2002	December 2, 2002
	Boston, Massachusetts	December 12, 2002	December 5, 2002
	Atlanta, Georgia	December 13, 2002	December 6, 2002

Your Contact Information:

First Name*

Middle Initial

Last Name*

Academic Degrees

Job Title*

Department

Division

Organization*

Address*

City*

State*

Country

Zip Code*

Telephone*

Fax

E-Mail*

If materials are sent out prior to the conference, do you want them sent to a different address?

If so, enter the full address here:

Special Needs/Accommodations:

Please indicate if you would like to participate in the lunch that will be provided on-site for a cost of $11 per participant.*

How did you hear about these workshops? (Please cirlce one)

E-Mail	Flyer	Fax
Web Site	Word-of-Mouth	Current Grantee
Other