REGISTRATION FORM 2004 Registration Fee: 120 Euros (includes Workshop kit, coffee/tea breaks, wine and cheese, excursion to historic site, copy of proceedings of 2001 workshop) Accommodation and meals per person per day in Euros Single Room - (A) Bed and breakfast: 45 Euros - (B) Bed, breakfast + 1 meal: 54 Euros - (C) Bed, breakfast + 2 meals: 60 Euros Twin-Bedded Room (with 2 single beds) - (D) Bed and breakfast: 40 Euros - (E) Bed, breakfast + 1 meal: 48 Euros - (F) Bed, breakfast + 2 meals: 54 Euros Triple Bedded Room (with 3 single beds) - (G) Bed and breakfast: 37 Euros - (H) Bed, breakfast + 1 meal: 45 Euros - (I) Bed, breakfast + 2 meals: 51 Euros Meals only - (J) Breakfast only: 2.60 Euros - (K) Packed Lunch: 6.70 Euros - (L) Extra Meal: 10.00 Euros - (M) Lunch/Supper (for guests): 14.50 Euros - (N) Children under 3 years: No charge - (O) Children 3-6 years: 50% Deposit Required: - registration, no accommodations: 120 Euros - registration + 1 day accommodation: 165 Euros Deposit required by 30 July 2004 (No registration will be accepted without deposit) All remaining fees due by first day of workshop If you are involved in maternal health care (which includes obstetrics, general practice, midwifery, nursing, anaesthesia, bioethics, neonatology, administration, etc) anywhere in the world and would be interested in attending the third International Workshop, please print, and complete the following form: You can email, mail, or fax it to : Mr. Simon Walley, MaterCare International, 8 Riverview Avenue, St. John's, Newfoundland, Canada A1C 2S5 Telephone: 709-579-6472, Fax: 709-579-6501, Email: info@matercare.org (Please write Rome registration 2004 in the Subject line) PLEASE PRINT CLEARLY NAME: ............................................................................................................................... ADDRESS: ........................................................................................................................ ........................................................................................................................................... Tel: .................................. (please include country code) Fax: .......................................... Email: ................................................................................................................................. Total Charges: _____ (A ,B ,or C...) x ____ # of individuals x ____# of nights = _________ (Please indicate number of single, double or triple rooms req'd) --------------------- x ______ = _________ Registration x ____ # of attendees = _________                                  TOTAL: _________ (Deposit and Fees maybe payable by money order, bank draft to MaterCare International (address above) in Euros. For VISA: Use form below or visit our secure website (www.matercare.org) Name (as it appears on card) ______________________________ (please print) VISA Number: ______________________________, Exp date: _____________.

For office use: DEP PA __________ Date_______. BAL REM __________. BAL PA _____ Date________.