HEALTH & BIOSCIENCE CURRICULUM CONFERENCE
Conference Announcement | Bay Area Health & Bioscience Careers Collaborative
R e g i s t r a t i o n F o r m
1 Name Ms./Mr./Dr.
5 Phone Fax Email
6* Home Address
7* Home Phone Social Security Number
* Residence and social security number information is required only if requesting stipend(s).
8 I am requesting a $200.00/day stipend for (please check) July 18 July 19.
You may choose to attend only day 1 (July 18), but preference will be given to those attending both days in the selection of stipend recipients. Stipend funds are limited, so apply early. Stipends will be paid after verification of all-day attendance at the conference.
CSU Hayward is a welcoming community. If you are disabled, have special needs or dietary restrictions, we will gladly accommodate your needs. Please list your needs below:
PLEASE PRINT AND FAX THIS FORM TO BETTE FELTON @ 925-602-6750 or MAIL TO: