Breast Cancer Foundation
First Name: Last Name: Title:
Address:
City: State: Zip: County:
Daytime Phone #: Fax #:
Email Address:
Name of Employer:
Employer Address:
City:
State:
Zip:
County:
Years of Experience in Mammography:
Registration Fee: $99—Please make check payable to Breast Cancer Foundation
A $40 administrative fee will be deducted for written cancellations postmarked prior to March 12, 2010.
No refunds for cancellations postmarked after March 13, 2010. The registration fee includes lectures, breaks, course manual and a certificate of attendance. Attendees will be on their own for lunch. There are several restaurants in the area as well as one in the Marriott Hotel.
Make checks payable and return to:
Breast Cancer Foundation
c/o Medical Imaging Physicians, Inc.
2591 Miamisburg Centerville Road, Ste. 302
Dayton, OH 45459
You will receive a confirmation notice after registration has been processed.
Seminar Location:
Marriott Hotel
1414 Patterson Blvd.
Dayton, OH 45409
Phone: (937) 223-1000
The Foundation has reserved a block of rooms at the Marriott Hotel, where the seminar is being held, for your convenience. Room rates are $99 single or double occupancy. Please call the Marriott Hotel directly for reseverations and to confirm availability and rates.
BOWL OVER CANCER 2009
Yes, we will participate in the “Bowl Over Cancer” Tournament to be held August 1.
Registration fee is $95 for team registration.
Make checks payable and return to:
Breast Cancer Foundation
c/o Medical Imaging Physicians, Inc.
Attn.: Patty Schneider
2591 Miamisburg Centerville Road, Suite 302
Dayton, OH 45459
T-shirts will be provided for participants and can be picked up by the team captain at the registration table.
Please enter name and mark size next to bowler’s name (S, M, L, XL or XXL, XXXL)
(ALL BOWLERS MUST BE AT LEAST 16 YEARS OF AGE)
Team Name:
Bowler 1: (Captain)Bowler 2: