Wufoo

Name * Title First Last Suffix
Institution *
Email *
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Registration Type *
Individual ($150) Institutional ($450) Local Institution ($150) Student ($85) Research Partner ($1000)

Please be aware that institutional registration includes up to 4 participants and Local Haitian Institution up to 2 registrants.
Additional Information

If you will require any airport transfers and/or hotel accommodations during the retreat, please mark the appropriate boxes. Retreat participants that reserve hotel accommodations through INURED will receive a discounted rate. (We will reserve doubles by default. Please indicate below in your comments if you would prefer a single).
Please check the appropriate boxes:
Airport Transfer ($50 r/t) Hotel Accommodation (July 21) Hotel Accommodation (July 22) Hotel Accommodation (July 23)
Please use the payment method that is most convenient. If paying by credit card, you will be taken to a secure PayPal payment page where you can pay by any major credit card.
Pay By *
Credit Card Check
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