GRACE Conference “On the Journey: Pregnancy * Infant loss * Infertility & Adoption” Online Registration Form for Conference Attendance Registration fee includes: breakout sessions, entrance to exhibition area & light refreshments. Walk-ins will be accepted, but lunch will not be guaranteed. Cancellation Policy: Registration fees can be refunded with a written cancellation received by March 20th. No refunds will be issued after March 20th. Administrative fee of $10 will be assessed. Please check all boxes that apply and fill in all applicable blanks. Please use a separate form for each individual or couple registering. When you finish the form click on the SUBMIT button at the bottom of this page. You can reset the form using the button at the bottom of the page. You will receive a confirmation email from us within 3 days of submitting your form, if you do not hear from us within that time please email us so we can be sure we received your form. Problems submitting this form online? You can register by mail by clicking here for a printable form (.pdf file). Conference Attendance Rates and Associated Fees Early Rates apply to forms received by March 15, 2004 Attendee Fri. Mar. 26 Sat. Mar. 27 Fri. & Sat. Mar. 26-27 Early Rate Regular Rate Early Rate Regular Rate Early Rate Regular Rate Individual $20 $22 $45 $50 $60 $66 Couple $30 $33 $65 $72 $90 $99 Professional (MT) $65 $72 $85 $94 Student (full time) $50 $55 $65 $72 Scholarship Box Lunch $10.95 Child Care ages 6 weeks - 5 years $15 $35 Child Care ages 6 - 14 years not available $25 Child Care family of 3 or more $65 Child's Box Lunch $6.95 Your name(s) and credentials Couples please register together, Individuals please fill out separate forms type exactly as you want printed on your name tag(s) Your organization's name (if applicable) Your phone number with area code Alternate phone number with area code Your mailing address Your email address I would like to join the Missing GRACE Organization Annual membership is $40 and includes: • $15 discount on registration fee for the conference • quarterly newsletter, email updates • GRACE tote bag filled with bereavement, infertility, and adoption resources I want to receive the newsletter: Online By mail How did you hear about the conference? Support Group Doctor's Office Website Radio TV Other, please specify: OPTIONAL: Please check all that apply, this helps us to recognize the needs of our attendees: Subsequent Pregnancy Infant Loss Infertility Adoption Doctor RN LPN Midwife Clergy Student List name(s) of your baby(s) and dates of birth/death Baby names included on registrations received by March 20th will be displayed on our GRACE Commemoration banner at the conference. Please check all that apply I want to attend but need scholarship assistance I want to sponsor an individual or family. Please note amount $ I would like to participate as a volunteer before and/or at the conference I want to register for the following sessions (please choose one option) Individual: Friday evening only Saturday only Friday and Saturday Couple: Friday evening only Saturday only Friday and Saturday Professional: Saturday only Friday and Saturday Full Time Student: Saturday only Friday and Saturday Please fill in the letter of the class you wish to attend each session. Indicate your first and second choices. Assignments are made in the order received. You will be notified of your sessions at registration. Click here for class descriptions (new window will open so you don't lose this form) Session 1 (A-D) first choice second choice Session 2 (A-D) first choice second choice Session 3 (A-D) first choice second choice Session 4 (A-E) first choice second choice I want to purchase a box lunch for Saturday Number of lunches: Large Croissant Sandwich: Turkey Roast Beef Ham Oriental Chicken Salad Vegetarian Wrap All lunches include choice of fresh fruit, soup, chips, dessert, & beverage. All Saturday snacks and beverages provided at no extra charge for both adults and children. I want to register my child/children for childcare for the following dates and times: (please check and fill in all that apply) Friday evening, 5:30pm to 9:00pm, ages 6 weeks - 5 years Name(s)/age(s) of child(ren) Saturday, 8:30am to 5:30pm, ages 6 weeks - 5 years Name(s)/age(s) of child(ren) Saturday, 8:30am to 5:30pm, ages 6 - 14 years Name(s)/age(s) of child(ren) Special Instructions? Number of kids' lunches Peanut Butter & Jelly Cheese Pizza Beef Hot Dog All lunches include choice of fresh fruit, chips, dessert, & beverage. All Saturday snacks and beverages provided at no extra charge for both adults and children. Any comments or questions related to any of the areas above? Payment Options Compute your total by referring to the table at the top of this page, be sure to include any extra items you signed up for (Missing GRACE membership, lunches, child care, sponsorships) and deduct $15 from your registration fee if you are a Missing GRACE member. Send check payable to the Missing Grace Organization to: The Missing GRACE Organization P.O. Box 1625 Maple Grove, MN 55311-6625 OR Send your payment online by credit card using the link to PayPal on the page that comes up after you submit this form. Please indicate how we should expect your payment: By mailBy PayPal Please review form before submitting

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