| First Name: |
Last Name:
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| Title/Dept.: |
Organization:
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| Street: |
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| City: |
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| Phone: |
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Fax:
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| Email: |
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Please list the Name(s) that apply to the following categories listed below.
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| CO-OP Annual Meeting Attendees: |
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Adult, Teen or Child Guest Attendees: |
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Please indicate how many of each item below you will be registering for:
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Saturday Night Hotel:
$139 (Susidized)*
room(s)
$159( Full Rate)
room(s)
* The Department of Community & Family Medicine has generously provided scholarship money
so we are able to offer a reduced rate, if needed.
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| Participant Meal Plan |
Accompanying Adult Meal Plan
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| Accompanying Teen Meal Plan
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Please mail your checks to the following:
Dartmouth CO-OP Project
Attn: DEBORAH J. JOHNSON, MHA
Dartmouth Medical School, HB 7250
Hanover, NH 03755
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