Registration Form

Please Print

Name                                                                                          

Address                                                                                       

City                                                                                              

State                             Zip                                

 
Daytime Telephone (       )                                                        

Email Address                                                                             

Fee Enclosed:

___  $30.00 2011 CPA member registration 

___   $50.00 Non-member registration 

___   $55.00 Conference registration and  2012 CPA membership

                          ___  New Member 

                             ___  Renewal 

Note:  If you are not a CPA member and wish to join please click here

Please make check payable to:

Connecticut Perinatal Association

Mail to :

Laurie Postemsky  

46 Shetucket Drive 

Windham, CT 06280