Registration Form

Seating is limited, so to reserve your place, please print this page and mail  the form to the address below

Attach your check, and please include you email address.

If you are registering after October 1st, please send an email to Lawrence.Silbart@uconn.edu and bring payment with you. Onsite registrants will be accommodated on a "space available" basis.

Return this form to: Jennifer Simoniello, Center for Environmental Health, 3636 Horsebarn Road, Ext., Unit 4040, Storrs Road, Storrs, CT 06269-4040. 

Please make checks payable to the University of Connecticut. Your registration will be confirmed upon receipt of the registration fee and registration form. If you have questions about the conference email: lawrence.silbart@uconn.edu.

Name_______________________________

Address _____________________________

Town ________________  State _________ Zip________

Phone ________________ Email:  __________________

Registration Fees:

Whole Conference (Lunch Included) $50.00 _________

Student Waiver* (No Lunch) Free _________

Total Amount Enclosed _________

*Non UCONN students may be asked to verify student status.