REGISTRATION FORM

11th Annual International Bioethics Forum:

Final Passages: Research on Near Death & the Experience of Dying

April 26-27, 2012
BioPharmaceutical Technology Center, Madison, WI

NOTE: Please be sure to set your browser to Internet Explorer to complete this form. Thanks!

Name 
Address
City
State
ZIP/Postal Code
Country
Phone
Fax
E-mail
Profession
No Dinner
Add Dinner 		Optional Thursday Night
Dinner with a Speaker ($65)
Please note: The drop-down menus below will be activated once you have selected “Add Dinner” above.
First Choice Second Choice Third Choice

The registration fee is $175 or $240 with optional dinner.

NOTE: After submitting your registration form you will be provided the option to pay online.

    

Checks made payable to "BTC Institute" should be sent to BTC Institute, 5445 East Cheryl Parkway, Madison, WI 53711. 

The BTC Institute will share your contact information with event sponsors, if so requested, unless you specifically advise us (BTC Institute) to keep that information confidential.