What We Do

Registration Form
Dying Well:
Medicine and Mortality through
Jewish, Christian, and Muslim Eyes

Please print

Name _________________________________________

Organization ___________________________________

Address _______________________________________

City __________________ State _________ Zip ______

Phone _________________________________________

E-mail address __________________________________

Would you like your e-mail listed in the roster?
      Yes      No

Professional Affiliation:

_____ Physician           _____ Nurse
_____ Psychiatrist        _____ Psychologist
_____ Social Worker     _____ Counselor
_____ Hospice Staff     _____ Hospice Volunteer
_____ Chaplain            _____ Congregational Clergy

Other (please specify) ____________________________

Religion and Denomination _________________________

REGISTRATION FEES:
Mail this form and a check payable to ICJS,
1316 Park Avenue, Baltimore, MD 21217

With continuing Education .............. $100.00
All others ...................................... $75.00

Registration is subject to space availability. If your res-ervation is accepted, you will receive confirmation in the mail. Please bring your confirmation to the conference.

No walk-ins can be accommodated.
Cancellation policy: No refunds after April 1, 2005.

For More Information:
Contact Laura Riger at 410-523-7227
or e-mail riger@icjs.org.

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The Institute for Christian & Jewish Studies
956 Dulaney Valley Road, Baltimore, MD 21204
410.494.7161 / fax: 410.494.7169
email: Info@icjs.org