Contact Information

First Name: ____________________________   Last Name: _____________________________

Address: _________________________________________________    ____ Home    ____ Work

City: ___________________________   State: ________________    Zip Code: ______________

Phone Number: ________________________      Email: ________________________________

Please print name as it should appear on nametag:

Additional Information

Occupation:

____Elementary School Teacher     ____Middle School Teacher     ____High School Teacher    

          ____Counselor     ____Nurse     ____Social Worker     ____Other:________________

School / Organization: ____________________________________________________________

School District (if applicable):______________________________________________________

Registration

Register by July 15^th and receive $25.00 off conference registration fee!

   ______ $50.00 if registering ON or BEFORE July 15, 2009

                       Look Both Ways must receive registration by July 15^th to be eligible for discount.

   ______  $75.00 if registering AFTER July 15, 2009

   ______  $5.00 additional fee if applying for Certified Health Education Specialist (CHES) Credit

Please complete this registration form and mail with check or money order to:

                    Look Both Ways, Inc

                    2216 Hoffman Dr. Unit B

                    Loveland, CO 80538

Please note that conference fees are non-refundable.

If you have any questions, please feel free to contact us at 970-667-9906

 or email us at info@lkbthwys.org