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Registration Form

 Please Print

Name                                                                                        

 Address                                                                                   

 City                                                                       

 State                               Zip                                       

Daytime Telephone (        )                                    

Fee Enclosed:

__ $30.00 2007 CPA member registration

__ $50.00 Non-member registration

__ $55.00 Conference registration  and 2008 CPA  membership  

    __ New Member 

    __ Renewal

 Please make check payable to:

Connecticut Perinatal Association

Mail to :

Susan Quimby

273 Cemetery Rd

Canterbury, CT  06331