The 2011 African American and Hispanic Leadership Conference on HIV/AIDS

ONLINE REGISTRATION

Now you can save time by conveniently Pre-Registering for the conference and paying your registration fee online securely using a debit or charge card or debit your checking account through "e-check".
Individual Registration Fee: $60.00
The deadline for Early Registration fees (the Early Individual Registration Fee of $50.00 and the Early Bird Group Registration Fee of $225.00 for five registrants) have now expired.

Please note: There is a $2.00 Online Processing Fee for each Online Registration.
If you are registering multiple participants you will need to pay for them and register them one at a time. There are no refunds on conference fees regardless of if you attend the conference or not.

INDIVIDUAL ONLINE LATE REGISTRATION
Participant First Name:*
Last Name*
Credentials
Occupation/Title
Employer

Address*

Street Address
Street Address Line 2
City	State
Zip Code

E-mail:*
Phone Number*
- Area Code Phone Number
....

I request vegetarian meals
Please Note:

When you hit submit below, you will be redirected to PayPal to pay your fee. If you do not complete your $62.00 payment with PayPal we will not receive your registration information. If you experience any difficulty with online registration or payment, please contact our web coordinator, Brad Hampton with Louisville Metro Public Health at (502) 574-8248. Thank you.
Should be Empty:

2011 African American and Hispanic Leadership Conference on HIV/AIDS

INDIVIDUAL ONLINE LATE REGISTRATION

Please Note: