Lawrence Hall of Science
University of California, Berkeley

Family Health Conference Registration

En Español

Name _____________________________________

Address ____________________________________

City _________________ State____ Zip________

Phone (       )______________________________

School ____________________________________

Address ___________________________________

City _________________ State____ Zip ________

Phone (       )_______________________________

I am a:
___ Teacher
___ Child care provider
___ Parent
___ Teen
___ Other ___________________

Choose one of the following Wellness Guides:  
_____English     
_____Spanish

Your ethnicity (optional): _____________________

If you are a teacher, what grade level do you teach? _________________

If you are a parent, how old are your children? ____________________

Have you attended any health workshops at LHS before? ___________________________

There is no fee for this conference.
To register for the conference, send a completed application to:

University of California, Berkeley
Family Health Conference
Lawrence Hall of Science # 5200
Berkeley, CA 94720-5200

Applications must be received by March 12, 2002
Applicants will receive confirmation of their enrollment and a map by March 19.

For more information, please call (510) 642-8963.