November 6 & 7, 2002

Marriott East

Indianapolis, IN

Registration Form

You should confirmation of receipt of the submission within 72 hours. 

 Contact Tom Neltner at mccabe@ikecoalition.org if you don't get confirmation within that time.  

THIS FORM IS NOT WORKING AT THIS TIME.  PLEASE EMAIL THE INFORMATION TO TOM NELTNER AT mccabe@ikecoalition.org.  OR SIMPLY ENTER THE INFORMATION IN THE FORM AND WHEN YOU GET THE VERIFIED REPORT CUT AND PASTE THAT INTO AN EMAIL TO TOM.  SORRY FOR THE INCONVENIENCE.

Five Easy Ways to Register
	Mail:	Print out and complete the registration form and mail with payment to: Improving Kids' Environment  5244 Carrollton Ave. Indianapolis, IN  46220-3181
	Phone:	317-442-3973 or 317-248-4848
	Fax:	866-234-8505 or 317-248-4846
	E-mail:	mccabe@ikecoalition.org
	Web:	Complete and submit this form

*Denotes field required for online submission

Title	*First Name	MI	*Last Name
SelectMr.Mrs.Ms.
Position/Job Title		Company/organization
Address		*E-mail
City		State	ZIP
*Daytime Phone		Fax

Fee Options
	Speaker	$0
	Exhibitor Booth - before October 10, 2002.  $250 after October 10	$200
	Exhibitor Table - before October 10, 2002.  $200 after October 10	$150
	Registration for First Person from Organization - before October 10, 2002.  $150 after October 10	$125
	Registration for Additional People from Organization - before October 10, 2002.  $125 after October 10.	$95
	Total Due

Payment Options
Check enclosed, payable to the Environmental Management Institute, Inc. If paying by check, form must be printed and mailed to the address below.
Credit Card Type		Card Number
Expires		Cardholder Name
Bill company	PO #	FEIN (required for invoicing)
Billing Address (If different from above)
City		State	ZIP
If you will need special accommodation, please check the box and a IKE will contact you.

Help Us Plan for You
Do you have special dietary needs?	Yes No
Describe
Check here if you do not want your name included on the conference roster.
Did you attend last year's Lead-Safe Indiana Conference	Yes No
How did you first hear about this program?
--Please select oneReferralIKE WebsiteBrochurePrint adArticleE-mailFax

Preferred Means of Communication Please continue to send IKE information by (check all that apply):
Mail	E-mail	Fax	Phone	Please remove my name from the mailing list

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Improving Kids' Environment 

5244 Carrollton Ave.

Indianapolis, IN  46220-3181

Phone:  317-442-3973
Fax: 866-234-8505 or 317-248-4846
E-mail: mccabe@ikecoalition.org

Page last modified August 18, 2002