REGISTRATION FOR THE 2012 SOUTHERN HARM REDUCTION AND DRUG POLICY CONFERENCE
Event Date: September 6th through September 8th, 2012
Event Times: Thursday 8am-5pm, Friday 9am-6pm, Saturday 10am-1pm
Event Location: Holiday Inn, Atlanta Capitol Conference Ctr, 450 Capitol Ave, Atlanta, GA
Please take a moment to register and complete this survey. If you have any questions, please contact Robert Childs, 336-543-8050   or via email at: robert@nchrc.net
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What is your last name? *
What is your first name? *
What organization or group are you affiliated with? *
Write "independent" if non-affiliated
What is your title with the affiliated organization or group? *
Write "N/A" if you do not have one
What is your email address? *
What is your phone number? *
What is your street address? Please include city, state and zip code *
Do you live in the US South? *
Primary Work or Volunteer Setting (MARK ONLY ONE) *
What is your primary role at your work setting? *
What services does your organization provide *
Required
What population does your organization focus its work on? *
Required
How many years have you worked in the field? *
Please enter a numeral
Demographic Information *
Gender
Required
Demographic Information
Race
How did you hear about this event? *
How do you plan on paying for the conference? *
Please copy the payment method so you can send payment accordingly. The conference costs $55 by check and $56 by PayPal (the $1 extra dollars represent PayPal's processing fees)
Notes to Conference Organizers
Please leave us a note here if you have any additional comments or questions
Thank you for registering!  As soon as your payment is processed we will send you a confirmation via email.  
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