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   2011 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 :

Susan Quimby

273 Cemetery Rd

Canterbury, CT 06331