ConnectCare | Registration Form

Name

*required field

School

*required field

School Work location address

*required field

School Mailing Address:

Telephone:

*required field

Email:

*required field

Please check all that apply.

	I will attend the workshop on November 2, 2011
	My work location (city) is more than 60 miles (one way) from Little Rock, and I am requesting lodging on November 2, 2011 (complete W-9 form prior to conference and sign TR 1 (#1012) mileage and lodging reimbursement forms at the conference)
	I will be driving to the workshop and request mileage reimbursement at the rate of $.42 per mile (complete W-9 form and return to Ida two weeks before the conference)
	Special diet
	I would like to invite the other school officials listed below to attend the workshop with me (list up to three).

Name

School

Title

Special Diet

Name

School

Title

Special Diet

Name

School

Title

Special Diet

A credit or debit card will be required at check-in, you will be reimbursed for the room .
Reimbursement will only be provided for participants who attend the entire workshop and complete all required forms for reimbursement.

Original hotel receipt will be required for reimbursement.

Reimbursement of the hotel rooms will be based on double occupancy, with a maximum of two rooms per school.
There will be no meals provided the night prior to the workshop.

PLEASE RETURN FORMS

Registration form can be completed on-line by October 7, 2011
W-9 form must be completed and received 2 weeks before the conference for reimbursement to Ida at the address below.

Ida King
AR Dept of Health,4815 West Markham, Slot 1
Little Rock, AR 72205
Phone 501-614-5916; Fax 501-280-4180
Ida.King@arkansas.gov
www.seeyourdoc.org