Please enter the attendee's email address and not the email address of the person completing the form

 NCHN Member 

 Not a NCHN Member 

 NCHN Business Partner 

 HRSA Network Development Grantee 

 HRSA Staff 

 Speaker 

Sponsor 

 Other 

This is the number of organizations that are members of your network (e.g., hospitals, clinics, etc). This data will be used as a tool for evaluating the potential reach of conference materials by conference participants.

Please indicate if you will attend these events and, if you have special dietary requirements, please include them here. We will do our best to accommodate them.

Your registration fee includes the following meals:

• Sunday Reception (cash bar and appetizers)
• Monday: Continental Breakfast, Awards Luncheon, Evening Dinner & Rockies Baseball Game
  
• Tuesday: Continental Breakfast, Networking Lunch, NRHA Opening of Exhibit Hall Reception
  
• Wednesday: Continental Breakfast

 I will attend this event 

 I will not be attending the reception 

 I will attend this event 

 I will not be attending the Monday Dinner & game 

 I will attend this event 

 I will not be attending NRHA's Opening Reception 

 I prefer a meat-based meal 

 I prefer a vegetarian meal 

 It does not matter 

Guests are welcome to attend the Sunday evening reception ($55 per person; includes appetizers) or Monday Night Dinner & Rockies Baseball Game ($85 includes food and entertainment). Please include name of your guest below.

Use this section to total your registration and guest fees and calculate your total due. You can pay with a credit card using Paypal or mail a check.

($600 for NCHN Members and current HRSA Network Development Grantees; $700 for non-Members)

($55 for Sunday Reception only; $85 for Monday Night Rockies Baseball Game only; $140 for both). Enter 0 if you will not be bringing a guest.

(a+b+c)

By completing this registration form and registering for the 2012 NCHN Annual Conference you are giving permission for your name and contact information to be published in any listing of conference participants that may be prepared and released by NCHN. In addition, by submitting your registration, you are agreeing to pay your registration fee ($525 for NCHN Members & Business Partners before April 1, 2012 and $600 after April 1, 2012; $625 for non-members before April 1, 2012 and $700 after April 1, 2012) and any applicable guest fees ($55 per person at the Sunday reception and $85 per person attending the Monday evening dinner).

Cancellation Policy
If for some unfortunate reason you should be unable to attend the 2012 NCHN Conference, after registering, NCHN will refund the registration fee if you meet the following guidelines. The 2012 Annual Conference Registration fee, minus $50 processing charge, will be refunded after the conference, if written cancellation is received by Christy Sullenberger at csullenberger@nchn.org by Monday, April 2, 2012. If a cancellation request is received after April 2, 2012, but before April 9, 2012, NCHN will credit the fee to a future NCHN meeting attended by December 2013. Unfortunately, if a cancellation request is received after Monday, April 9, 2012, NCHN cannot refund the registration fee. If the fee has not already been paid, it will be due upon receipt of an invoice from NCHN. NCHN is unable to provide a refund after April 9, 2012 because NCHN will be committed to the hotel for included meal costs and other cost associated with the management of such a conference. If you should need to cancel after April 9 and wish to send a substitute, NCHN will switch the registration to the new conference attendee, but cannot guarantee that this person will be included in the conference listing of participants and/or have a printed name tag. If you have questions about the cancellation policy, please check with Christy Sullenberger at csullenberger@nchn.org