Last Name: *
First Name: *
Degree(s):
Title:
Institution/Organization: *
Street:
City:
State:
Zip Code:
Daytime Phone (with area code):
Fax (with area code):
Email Address: *

Number of Registrants:
Individual
Multiple Individuals
Table of Ten

If you are purchasing a table of 10 ($500), how would you like to be recognized in the program?
Anonymous
Name/Organization
Not applicable

Please mark your intended form of payment:
Check (payable through U.S. banks only) payable to Texas Medical Center Women's Health Network. Checks may be mailed to Pamela Lyle, CFO, The Rose, 12700 N. Featherwood, Ste. 260, Houston, TX 77034
Money order
Credit Card (We use Paypal for credit cards. You do not have to be a member of PayPal to use your credit card. This option is available once you hit "Submit").


An email will be sent to you within ten working days of receipt of your registration.

Refund/Cancellation Policy

The registration fee is non-refundable.  Registration at the conference is limited and may not be available. In case of activity cancellation, the liability of the TMC-WHN is limited to the registration fee which will be refunded to individuals who provide sufficient contact information. The TMC-WHN reserves the right to limit the number of participants in a program and is not responsible for any expenses incurred by an individual whose registration is not confirmed and for whom space is not available.