Registrant Information
Full Name (with credentials):
Company or Organization (if applicable):
Address:
City:
State:
Zip:
Day Phone:
Evening Phone:
Email:

Guest Names (please list the full names of any guests you'll be paying for, with their credentials): 

How did you hear about the Innovating for Continence Conference?

Please register me and my guests as (note: this fee does not include the optional pre-conference workshops listed below):
General Registration: $450
Allied Health Professional: $300
Student: $175 (click here for information about a travel award that is available for students)
Individual with Incontinence: $175

Please also register me and my guests for the following optional pre-conference workshops on Monday, April 6th (workshops are $50 each, per person - this fee is not included in the conference registration):
1:00-6:00pm: Innovating Beyond Technology
4:00-5:30pm: From Concept to Market: Development Cycle of Biomedical Devices
6:30-9:30pm: Technology and Managing Incontinence: Where are the Gaps and Needs?

How I'd like to pay for the conference:
I will mail a paper check or money order made payable to "The Simon Foundation"
Please email me an invoice from PayPal so that I may pay online with a credit card or electronic check. (Please double-check that your email address listed above is correct.) Please note: PayPal invoices will not be issued until after October 6th, 2008.

I understand that by clicking the "Submit" button below, I am officially registering myself, and any additional guests that I have listed, for the Innovating for Continence Conference. I have entered the correct contact information for myself, including a current email address. I agree to pay for the conference through the method I have selected above within 5 business days. If I selected to pay through PayPal, I understand that an invoice will be emailed to me after October 6th with instructions for payment. If I selected to pay by paper check or money order, I will make my payment payable to "The Simon Foundation", and mail it within five business days to:

Innovating for Continence
c/o The Simon Foundation
PO Box 815
Wilmette, IL 60091