CONFERENCE REGISTRATION FORM* (Please duplicate for …March 9, 2020. • Cancellations received...
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CONFERENCE REGISTRATION FORM* (Please duplicate for each registrant) Please type. No telephone reservations will be accepted. A. ABOUT YOU Name ______________________________________________________________________________________________ Name on Badge _______________________________________________________________________________________ Title _______________________________________________________________________________________________ Organization _________________________________________________________________________________________ Address_______________________________________________________________________________________________ City ________________________________________________ State _____________ Zip _______________________ Email Address _________________________________________________________________________________________ Phone (______) _______________________________________ Fax (______)____________________________________ Admin Contact _______________________________________ Phone (______)_________________________________ Dietary Needs (ex. Kosher, Vegetarian, Food Allergies, etc.) _______________________________________________________ Is this your first time attending a NACHC conference? yes no I am a speaker/moderator yes no Speakers/Moderators qualify for a $50 discount on registration fees and must register in order to participate. No thanks, my session only. I would like to opt-out of exhibitor mailings for NACHC Conferences. B. ATTENDANCE METHOD (Check one) ATTEND ON-SITE ATTEND ON-LINE C. TO REGISTER FOR FULL CONFERENCE On/Before February 24 After February 24 NACHC Member Organizations in Good Standing (Paid thru 3/31/20 or later) Does not apply to Individual Memberships First and second registrant from an organization $1,325 __________ $1,460 __________ ird or more registrants from same organization $1,275 __________ $1,435 __________ Non-Member Organizations First and second registrant from an organization $2,575 __________ $2,805 __________ ird or more registrants from same organization $2,535 __________ $2,735 __________ Other Federal Government Officials $1,325 __________ $1,460 __________ Full-Time Under-Graduate Students $710 __________ $805 __________ (Photo-copy of I.D. required with this form.) D. TO REGISTER FOR ONLY ONE DAY (If NOT Attending FULL CONFERENCE) Monday Tuesday Wednesday ursday Please check appropriate day (includes full conference activities on a specific day) On/Before February 24 After February 24 NACHC Member Organizations (per person, per day) $945 __________ $1,080 __________ Non-Member (per person, per day) $1,820 __________ $2,085 __________ E. TICKETED EDUCATIONAL SESSIONS & EVENTS Space is Limited and Registration is Necessary Board Member Boot Camp (Sunday, March 15) Member Non-member First and second registrant from an organization $250* __________ $500* __________ ird or more registrants from same organization $230* __________ $460* __________ *REGISTRATION IS NECESSARY BUT FEE IS NOT REQUIRED IF YOU ARE ATTENDING & PAYING THE FULL CONFERENCE FEE. Board Member Boot Camp is only being offered in-person at P&I. F. NEW! LEARNING LABS Pre-registration is Required. Learning Labs are available ONLY to full-paying registrants. Preparing for a Board Leadership Role (March 18) — Limited to 60 $25 per person $ __________ G. NACHC USER GROUPS Sunday, March 15 8:00am – 9:30am NACHC athenaOne User Group — Limited to 60 10:30am – 12:00pm NACHC Greenway Intergy User Group - Limited to 60 1:00pm – 2:30pm NACHC eClinicalWorks User Group - Limited to 60 Monday, March 16 8:00am – 9:30am NACHC Centricity User Group — Limited to 60 10:30am – 12:00pm NACHC NextGen User Group — Limited to 60 GRAND TOTAL ENCLOSED $ ___________ H. PAYMENT INFORMATION (Payment MUST be received with registration form.) My check is enclosed and made payable to NACHC. Please charge my: Master Card Visa American Express Card Number: _______________________________________________________________________Expiration Date: __________ Name as it appears on card: ____________________________________________________________________________________ Card Holder’s Signature: ______________________________________________________________________________________ 2020 POLICY & ISSUES FORUM March 16-19, 2020 Marriott Wardman Park Hotel 2660 Woodley Road, NW Washington, DC 20008 (202) 328-2000 Three Ways To Register: ELECTRONICALLY Find this registration form on line at http://nachc.org/conferences/ policy-and-issues/pi-registration/. You may register automatically with a credit card or you can print the form and mail it with your check. MAIL Mail Registration to: NACHC Meetings/Acct. Dept. 7501 Wisconsin Avenue, Suite 1100W Bethesda, MD 20814 FAX Send registration form with credit card information to (301) 347-0457. Registration forms will not be processed without payment. EARLY-BIRD REGISTRATIONS FEES: Only apply until Monday, February 24, 2020. NACHC CANCELLATION POLICY: All cancellations must be in writing and must be received at NACHC on/before Monday, March 9, 2020. • Cancellations received on/before Monday, March 9, 2020 will be assessed a $100 processing fee. (Allow 6–8 weeks following the conclusion of the conference for all refunds.) • Cancellations received after Monday, March 9, 2020 are non-refundable. • Cancellations after the conclusion of the conference are non-refundable. • “No Shows” are non-refundable. • Participants sending registrations after Friday, February 28, 2020 will be handled as “On-site Registrants”. DO NOT mail your forms after Friday, February 28, 2020. Please bring your registration form and payment (credit card/organizational check) to the “On- Site Registration” counter at NACHC registration. For NACHC use only: Pay thru date: _________________________ Check #: ____________________________ Batch #: _____________________________ *By registering for this conference, you will be added to the Health Center Advocacy Network and will receive policy and advocacy email communications from NACHC. ®
Transcript of CONFERENCE REGISTRATION FORM* (Please duplicate for …March 9, 2020. • Cancellations received...
CONFERENCE REGISTRATION FORM* (Please duplicate for each registrant)Please type. No telephone reservations will be accepted.
A. ABOUT YOU
Name ______________________________________________________________________________________________
Name on Badge _______________________________________________________________________________________
Title _______________________________________________________________________________________________
Organization _________________________________________________________________________________________
Address _______________________________________________________________________________________________
City ________________________________________________ State _____________ Zip _______________________
Email Address _________________________________________________________________________________________
Phone (______) _______________________________________ Fax (______)____________________________________
Admin Contact _______________________________________ Phone (______)_________________________________
Dietary Needs (ex. Kosher, Vegetarian, Food Allergies, etc.) _______________________________________________________
Is this your first time attending a NACHC conference? yes no
I am a speaker/moderator yes no Speakers/Moderators qualify for a $50 discount on registration fees and must register in order to participate. No thanks, my session only.
I would like to opt-out of exhibitor mailings for NACHC Conferences.
B. ATTENDANCE METHOD(Check one) ATTEND ON-SITE ATTEND ON-LINE
C. TO REGISTER FOR FULL CONFERENCE On/Before February 24 After February 24NACHC Member Organizations in Good Standing (Paid thru 3/31/20 or later) Does not apply to Individual Memberships First and second registrant from an organization $1,325 __________ $1,460 __________ Third or more registrants from same organization $1,275 __________ $1,435 __________
Non-Member Organizations First and second registrant from an organization $2,575 __________ $2,805 __________ Third or more registrants from same organization $2,535 __________ $2,735 __________
Other Federal Government Officials $1,325 __________ $1,460 __________ Full-Time Under-Graduate Students $710 __________ $805 __________ (Photo-copy of I.D. required with this form.)
D. TO REGISTER FOR ONLY ONE DAY (If NOT Attending FULL CONFERENCE)
Monday Tuesday Wednesday ThursdayPlease check appropriate day (includes full conference activities on a specific day) On/Before February 24 After February 24NACHC Member Organizations (per person, per day) $945 __________ $1,080 __________Non-Member (per person, per day) $1,820 __________ $2,085 __________
E. TICKETED EDUCATIONAL SESSIONS & EVENTS Space is Limited and Registration is Necessary Board Member Boot Camp (Sunday, March 15) Member Non-member First and second registrant from an organization $250* __________ $500* __________ Third or more registrants from same organization $230* __________ $460* __________
*REGISTRATION IS NECESSARY BUT FEE IS NOT REQUIRED IF YOU ARE ATTENDING & PAYING THE FULL CONFERENCE FEE.
Board Member Boot Camp is only being offered in-person at P&I.
F. NEW! LEARNING LABS Pre-registration is Required. Learning Labs are available ONLY to full-paying registrants. Preparing for a Board Leadership Role (March 18) — Limited to 60 $25 per person $ __________
G. NACHC USER GROUPS Sunday, March 15 8:00am – 9:30am NACHC athenaOne User Group — Limited to 60 10:30am – 12:00pm NACHC Greenway Intergy User Group - Limited to 60 1:00pm – 2:30pm NACHC eClinicalWorks User Group - Limited to 60Monday, March 16 8:00am – 9:30am NACHC Centricity User Group — Limited to 60 10:30am – 12:00pm NACHC NextGen User Group — Limited to 60
GRAND TOTAL ENCLOSED $ ___________
H. PAYMENT INFORMATION (Payment MUST be received with registration form.)
My check is enclosed and made payable to NACHC. Please charge my: Master Card Visa American Express
Card Number: _______________________________________________________________________Expiration Date: __________
Name as it appears on card: ____________________________________________________________________________________
Card Holder’s Signature: ______________________________________________________________________________________
2020 POLICY & ISSUES
FORUMMarch 16-19, 2020
Marriott Wardman Park Hotel2660 Woodley Road, NWWashington, DC 20008
(202) 328-2000
Three Ways To Register:
ELECTRONICALLYFind this registration form on line at http://nachc.org/conferences/policy-and-issues/pi-registration/. You may register automatically with a credit card or you can print the form and mail it with your check.
MAILMail Registration to:NACHC Meetings/Acct. Dept.7501 Wisconsin Avenue, Suite 1100WBethesda, MD 20814
FAXSend registration form with credit card information to (301) 347-0457. Registration forms will not be processed without payment.
EARLY-BIRD REGISTRATIONS FEES: Only apply until Monday, February 24, 2020.
NACHC CANCELLATION POLICY: All cancellations must be in writing and must be received at NACHC on/before Monday, March 9, 2020.
• Cancellations received on/before Monday, March 9, 2020 will be assessed a $100 processing fee. (Allow 6–8 weeks following the conclusion of the conference for all refunds.)
• Cancellations received after Monday, March 9, 2020 are non-refundable.
• Cancellations after the conclusion of the conference are non-refundable.
• “No Shows” are non-refundable.
• Participants sending registrations after Friday, February 28, 2020 will be handled as “On-site Registrants”.
DO NOT mail your forms after Friday, February 28, 2020. Please bring your registration form and payment (credit card/organizational check) to the “On-Site Registration” counter at NACHC registration.
For NACHC use only:
Pay thru date: _________________________
Check #: ____________________________
Batch #: _____________________________*By registering for this conference, you will be added to the Health Center Advocacy Network and will receive policy and advocacy email communications from NACHC.
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