HEALTH & BIOSCIENCE CURRICULUM CONFERENCE
CSU Hayward - Contra Costa Campus
JULY 18-19, 2002

Conference Announcement  |  Bay Area Health & Bioscience Careers Collaborative

R e g i s t r a t i o n   F o r m
(This form is printable. Please do so and return by fax or mail.)

1  Name Ms./Mr./Dr. 
                                       (Last, First, M.I.)

2  Position 

3  Institution/Organization 

4  Address 
                                       (Street, City, Zip)

5  Phone   Fax   Email 

6*  Home Address 
                                              (Street, City, Zip)

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:

Bette Felton, Interim Dean

CSU Hayward Contra Costa Campus

4700 Ygnacio Valley Road, Concord, California 94521

Questions? Comments? Please contact Bette Felton @ 925-602-6767