HIV/AIDS Workshop for Medical & Religious Professionals

Registration Deadline: January 27, 2005

Cost: $25

Number of Persons attending ____________

Total Amount Enclosed ________________

Main Contact information:

Name ______________________________________________________

Address ____________________________________________________

Phone _____________________________________________________

Email ______________________________________________________

Names of others in group ______________________________________

CME credits desired? Yes or No

CE credits desired? Yes or no

Medical Professional? r

Religious Professional? r

Other? r

Payment:

r Check (make payable to Zygon Center for Religion and Science)

r Credit Card

Name as it appears on card: ____________________

Number: ___________________________________

Expiration Date: _____________________________

Signature: __________________________________

Please fax (credit card registrations only) or mail form with payment to ZCRS:

Zygon Center for Religion and Science

1100 East 55^th Street, Chicago, IL 60615

Fax: 773-256-0682