WOMEN’S HEALTH CONFERENCE Saturday, April 25, 2015 First Name: ______________________________Last Name: ______________________________________ Address: ________________________________ City: ___________________________________________ State/Province: __________________________ Zip/Postal Code: _________________________________ Telephone: (______) ______________________ Cell Phone: ______________________________________ Email: __________________________________ HEALTH CONFERENCE INFORMATION: Registration 8:00 a.m. Breakfast & Networking 9:00 a.m. Conference 9:15 a.m. Breakfast and Lunch: Vegetarian lunch required? Yes or No  (please check one) Please list any special dietary needs: ____________________________________________________ Workshops and information: Health, Nutrition, Mental Health, Beauty, Fun and Exercise REGISTRATION FEE $ 20.00 in Advance TOTAL ENCLOSED $_________ PAYMENT METHOD:  Money Order  Check Please check appropriate box. Please make Check or Money Order to: Cross Street A.M.E. Zion Church. There will be a $25.00 fee charged for returned checks due to insufficient funds. (Please note that no refunds will be given.) Please mail registration form and checks to: Please do not mail cash. 2013 Women’s Health Conference c/o Anita Dempsey-White Cross Street A.M.E. Zion Church 440 West Street Middletown, CT 06457 Any questions, please call Anita Dempsey-White at (860) 770-4644 or email adzumbalady.dempsey@gmail.com or contact church directly at (860) 344-9527. Fearless Women in 2015 Program information: www.crossstreetamezion.org