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LIDA
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Mother Friendly Childbirth Initiative
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Event Registration Form
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Daytime Phone Number
*
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Evening Phone Number
*
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Email
*
Please select the event you wish to register for:
*
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CPR Certification ($40.00)
PMD Workshop ($90.00 or $80.00 for LIDA members)
please select one
I am unable to attend. Please accept my donation of:
*
Payment made by:
*
Check: Please make checks to LIDA, Inc and mail to 40 Beecher Ave, East Islip, NY 11730
Intuit: If paying by Intuit please follow the link to the right.
Credit Card: If paying by credit please complete below.
This link will open the Intuit website in a new window where you will make your payment.
YOU MUST STILL COMPLETE THIS FORM AND CLICK SUBMIT
below for LIDA to be provided with your personal information.
To pay via Intuit please click here
Name exactly as it appears on card
*
Account Number
*
Type of card
*
VISA
Mastercard
Exp. Date
*
CVV code
*
3 digit code on the back of your card
Amount to be charged to card
*
multiply number of tickets by $15.00
ZIP Code of billing address for credit card
*
Comment
*
Submit