2015 IMAGE Conference Registration Form NAHCR Executive Office, P.O. Box 14365, Lenexa, KS 66285-4365 Fax: 913-895-4652 Register Online: www.nahcr.com
Deadline for advance registration is July 1, 2015. Registrations after this date must be completed on-site at the conference. STEP ONE: REGISTRATION INFORMATION Please list your name exactly as you would like it to appear on your name badge: (*these items may appear in the registration roster) I do NOT want my name to appear on the pre-registration roster. *Name__________________________________________________________________________________________________________________ *Credentials (e.g., RN, BSN, CHCR – limit 3)________________________________ Title______________________________________________ *Organization____________________________________________________________________________________________________________ Address_________________________________________________________________________________________________________________ *City________________________________________ *State_______________ Zip______________________*Country________________________ *Phone______________________________________________________ Cell Phone__________________________________________________ *Email___________________________________________________________________________________________________________________
SPECIAL NEEDS
EMERGENCY CONTACT INFORMATION
I will need assistance with:________________________________
Name_____________________________________________________
I have the following dietary requirements: Vegetarian Vegan Gluten-Free Diabetic Kosher Other _______________________________________________
Relationship________________________________________________ Phone Number_____________________________________________
This is my first IMAGE Conference. I am a new NAHCR Member. I am aware that my photo may be taken during the conference and may be published on NAHCR social media sites, NAHCR’s website and in publications to promote NAHCR and the IMAGE Conference.
STEP TWO: REGISTRATION – MEMBERS
REGISTRATION – NON-MEMBERS
PRE-CONFERENCE WORKSHOPS
PRE-CONFERENCE WORKSHOPS
Pre-Conference Workshop 1 Pre-Conference Workshop 2 Pre-Conference Workshop 3 Pre-Conference Workshop 4
On or Before After 6/1/15 6/1/15 $300 $400 $300 $400 $300 $400 $300 $400
BUNDLE – MEMBERS Conference and Half-Day Workshop $850 Workshops: 1 or 2 or 3 or 4 FULL CONFERENCE ONLY – MEMBERS Member
$950
Pre-Conference Workshop 1 Pre-Conference Workshop 2 Pre-Conference Workshop 3 Pre-Conference Workshop 4
On or Before 6/1/15 $450 $450 $450 $450
BUNDLE – NON-MEMBERS Conference and Half-Day Workshop $1150 Workshops: 1 or 2 or 3 or 4
After 6/1/15 $550 $550 $550 $550 $1275
$675
$775
FULL CONFERENCE ONLY – NON-MEMBERS Non-Member $975
$1075
SINGLE-DAY REGISTRATION – MEMBERS Wednesday, July 22 $345 Thursday, July 23 $345 $345 Friday, July 24
$345 $345 $345
SINGLE-DAY REGISTRATION – NON-MEMBERS Wednesday, July 22 $445 Thursday, July 23 $445 $445 Friday, July 24
$445 $445 $445
0 Total Member Registration Fees: $__________
Total Non-Member Registration Fees:
0 $__________
2015 IMAGE Conference Registration Form, continued Name ����������������������������������������������������
STEP SIX: TOTAL FEES ENCLOSED
STEP THREE: AWARDS LUNCHEON & RAFFLE TICKETS
Total Registration Fees
0 $__________
Awards Luncheon Tickets (for guests or Friday-Only Registrants) ___ × $69
Total Awards Lunch Ticket Fees
0 $__________
Total Raffle Ticket Fees
0 $__________
Guest Name(s)____________________________________________
Total Awards Lunch Ticket Fees:
0 $__________
Giving for Good – 50/50 Raffle $1 for 1 Ticket
0 $__________
All funds must be submitted on a U.S. bank in U.S. funds. NAHCR does not accept purchase orders or invoice for services. NAHCR Tax ID: 75-1650774. Check made payable to NAHCR – check #__________
Total tickets ________ x $1
TOTAL ENCLOSED:
Total Raffle Ticket Fees:
0 $__________
Charge payment to the following credit card: VISA MasterCard Amex Discover
STEP FOUR: CONCURRENT SESSIONS
_________________________________________________________
Please review the IMAGE Conference schedule and indicate below the concurrent sessions that you think you would be interested in attending. You will not be mandated to attend the sessions chosen below; the information will be used for internal planning purposes only and is subject to change.
Credit Card Number
Thursday, July 23 2:00 p.m. - 3:00 p.m. 1A 1B 1C 3:05 p.m. - 4:05 p.m. 2A 2B 2C 4:10 p.m. - 5:10 p.m. 3A 3B 3C
Friday, July 24 10:45 a.m. - 11:45 a.m. 4A 4B 4C
Expiration Date
_________________________________________________________ Name as it appears on card
_________________________________________________________ Signature Date
_________________________________________________________ Contact Phone of Cardholder
STEP SEVEN: SUBMIT REGISTRATION FORM Please return the registration form and total amount due to: Mail: NAHCR Executive Office Overnight Courier Only: P.O. Box 14365 NAHCR Executive Office Lenexa, KS 66285-4365 18000 W. 105th St. Olathe, KS 66061 Fax:
The following events are included in your registration fee. Please indicate if you will be attending: Health Care Recruitment Thought Leader Coffee Chat Kick-Off to IMAGE Reception sponsored by Exhibit Hall Opening Reception sponsored by Awards Luncheon sponsored by (included in conference registration fee; tickets required for Friday-only registrants or guests)
SAVE
Fax completed registration form with credit card payment to 913-895-4652 or register online.
Questions?
STEP FIVE: OPTIONAL EVENTS
_________________________________________________________
RESET
Contact the NAHCR Executive Office at 913-895-4627 or NAHCR@goAMP.com.
Cancellations & Transfers
Cancellations and transfers must be requested in writing and postmarked, faxed or emailed by July 1, 2015. Refunds will be issued following the conference. A $50 administrative fee will be assessed. Cancellation requests must include the reason for the cancellation. If you transfer your registration to another person, please include a completed registration form for that person with your written request. Requests for cancellation postmarked, emailed or faxed after July 1, 2015, are not refundable. If you wish to register after July 1, please bring your completed registration form and payment with you to the conference.
Please log on to www.nahcr.com and update your demographic information. After logging on, click “Member Services,” “My Account” and then “Personal” to place a check in each box that applies to you. Please note that any changes to your name, designation, organization, email or phone will not be updated on your conference registration. You must contact the Executive Office at NAHCR@goAMP.com to make any changes to this registration.