2001: A Pulmonary Odyssey registration form

...young asthmatics have the time of their lives as they learn how to keep asthma from controlling their lives.

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2001: A Pulmonary Odyssey
Sponsored by the American Thoracic Society and
the American Lung Association of Kentucky
March 24 & 25, 2000 � Lexington, KY � Embassy Suites

Last Name:
First Name:
	MD RN RT Student Other
Street Address or P.O. Box:
City:
State:
Zip:
Daytime phone w/ area code:
Fax:
E-Mail Address:

Registration Fees (Check only one please)
MD:	2 day $100 1 day $60
RN:	2 day $60 1 day $35
RT:	2 day $60 1 day $35
Student:	2 day $60 1 day $35
Other:	2 day $60 1 day $35
	Specify which day:
If other, please specify your title:

Optional tax-deductible donation to KY ASTHMATTACK! to fund asthma research:

Total amount to be charged to credit card:
Method of Payment for On-Line Registration
Please bill my credit card
Check one:	VISA MasterCard
Account #:
Expiration Date: (mm/yy)

American Lung Association of Kentucky
P.O. Box 9067 � Louisville, KY 40209-0067
Phone: 502-363-2652 � 1-800-LUNG-USA
e-mail: info@kylung.org

Copyright 2008 American Lung Association of Kentucky
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