PREVENTING HEROIN OVERDOSE: PRAGMATIC APPROACHES
Sheraton Hotel, Seattle, January 13-14, 2000
Sponsored by the UW Alcohol and Drug Abuse Institute and The Lindesmith Center

Registration Form Instructions:

  1. Fill out the form below on-screen
  2. Use your browser's PRINT function to print the completed form
  3. Mail this form, with payment, to the address given below.
Registration fee of $75 US ($40 US for students) includes all conference sessions and materials, a reception on Thursday evening, continental breakfasts, and lunch on Friday.

Deadline: Registration form and payment are due Dec. 30, 1999; late registration will be accepted if space is available. Refunds (less $25 processing fee) will only be provided for cancellations prior to Dec. 31, 1999. Advance registration is strongly recommended to guarantee space.

Name: Title:
E-Mail:

Organization:
Street Address:     
City: Province/State:
Postal Code: Country:
Telephone: Fax:

If registering as a student, note University and anticipated date of degree:
Please describe dietary restrictions or disability accommodations required:
Will you be lodging at the conference hotel (Sheraton)? No   Yes   Number of nights:

Payment Options:

Check or money order enclosed, payable to University of Washington (federal I.D. # 91-6001537). All payments must be in U.S. funds.

Charge credit card: American Express VISA Mastercard
Number:   Exp. Date:

Signature : _____________________________________________________

Please mail completed form and payment to:
Heroin OD Conference Registration
Alcohol and Drug Abuse Institute; University of Washington
Box 351415, Seattle, WA 98105-6696 USA.
If using a credit card, you may fax completed form to: (206) 543-5473
If you have questions, please contact ADAI at (206) 543-0937 or adai@u.washington.edu
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