Laying the Foundation for Hospice Volunteer Programs and
Maximizing Volunteers: Developing “Gold Standard” Programs

*First Name

*Last Name

*Title

*Agency Name

*Address

Address 2

*City

*State

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*Zip Code

*Phone

*Email Address

OPTIONAL - 2nd Email Address: Use this field if you would like to receive the initial confirmation email at an additional address.

Only Attending the "Maximizing Volunteers" Workshop

Hospice Provider Members:

Hospice Provider Members by 1/15/10 - $135 Hospice Provider Members from 1/16/10 until 2/4/10 - $155 Hospice Provider Members after 2/4/10 - $185

Non-Members:

Non-Members by 1/15/10 - $270 Non-Members from 1/16/10 until 2/4/10 - $310 Non-Members after 2/4/10 - $370

Only Attending the "Laying the Foundation for Volunteer" Workshop

Hospice Provider Members:

Hospice Provider Members by 1/15/10 - $75 Hospice Provider Members from 1/16/10 until 2/4/10 - $95 Hospice Provider Members after 2/4/10 - $115

Non-Members

Non-Members by 1/15/10 - $150 Non-Members from 1/16/10 until 2/4/10 - $195 Non-Members after 2/4/10 - $230

Attending Both Workshops:

Hospice Provider Members:

Hospice Provider Members by 1/15/10 - $185 Hospice Provider Members from 1/16/10 until 2/4/10 - $205 Hospice Provider Members after 2/4/10 - $225

Non-Members:

Non-Members by 1/15/10 - $370 Non-Members from 1/16/10 until 2/4/10 - $410 Non-Members after 2/4/10 - $450

Payment Method

Visa Master Card Discovery Card Bill Me/Agency Purchase Order

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Billing Address (if different from above):

Credit Card Number:

Expiration Date

3-Digit Security Code on Back of Credit Card

If paying by purchase order, please include your PO number in this field.

ADA Requirements

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