Registration Form
NETS DAY 2006: BABY TALK 
(confirmation letter will be sent  to you).

Name:                                                                    
Discipline(circle one):
RN     NNP     CNM   RRT     EMT    MD    other:____________ 

Address:                                                                           

                                                                              ______

                                                                              ______

Telephone Number:                                                                

Place of Employment:                                                                

E-mail address:                                                                 

Dietary Restrictions (if any)                                             
[    ] I need directions to the Omni. 
(We will provide them with your confirmation letter.)       

Breakout Session I wish to attend: (please circle one)
      I                       II                     III

Conference Fee:  
(Before May 1)     $65.00 
(After    May 1)      $75.00
UVa employees   $45.00

Make checks payable to: UVA Fund
Please write “ NETS Day 2006” in memo section

Mail to:
NETS Team NICU/7 East
P.O. Box 801430
UVA Medical Center
Lane Road
Charlottesville , VA 22908

Hotel, Parking, and Program Credits

NETS

For information or questions
Call 434-924-9853 and ask for Jane Dwyer or the clinician on call.