KIM: Kids In Motion

KIM Conference/Pre-Conference:
Attendee Registration

Conference registration includes:
2 full breakfasts, 2 full lunches, 2 afternoon snacks and
1 evening reception

Please fill in the information below. Required fields are noted with an asterisk (*).

Personal Information

First Name: *	Last Name: *
Title:	Organization:
Years a tech/instructor:

Emergency Information

Emergency First Name: *	Emergency Last Name: *
Relationship: *	Phone: *

Address Information

Street Address: *
City: *	State (or Province): *
ZIP: *	eMail: *
Phone: *
Check here if any information needs to be private:
List private items from above:
Special Dietary Needs/ any allergies / medical conditions:

Payment Information fee

An Additional $25 must be added to each pre-conference session if you are not attending the KIM Conference.

Register for the KIM conference:

Register for "Hospital CPS" morning session:

Register for the "School bus" morning session:

Register for the "Safety for sale" afternoon session:

Register for the "Leadership enrichment" afternoon session:

Number of additional family member eating meals ($225 each):

How will you be paying? (All payments in US currency) *

Purchase Order #: