Registration Form for Media Conference 2002

To confirm your participation, please complete this form, and click the submit button at the bottom. After you submit your registration information, you can choose to pay the conference registration fee of $25 via credit card thru our secure service. Alternatively, this form can be printed and mailed along with the $25 registration fee payable to "KWRU" to:

Rachel Gazda

P.O. Box 50678

Philadelphia, PA 19132

Registration is $25. No one will be turned away for lack of funds.

Questions? Call: 215.203.1948 or email conference@kwru.org

Name:

Organization:

Address:

City: State: Zip:

Phone: Fax:

Email:

Special Needs:

Do you need housing? Yes No

Smoker Non-Smoker

Thank you for your registration!

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