2014 Congress on Healthcare Leadership - (Page 63)

✂ REGISTRATION INFORMATION 63 SECTION 5: Dinner SECTION 7: Personal Information Purchase Modern Healthcare Dinner Please PRINT your name as it appears on your ACHE record or your mailing label. would like to attend the Modern Healthcare Health Care Hall of Fame award presentations and dinner on Sunday, March 23. The fee is $190 per person. Guest name(s) ❍ I Total fee for Modern Healthcare event $ SECTION 6: Purchase Special Events Select from any of the following: ❍ Joint Federal Sector Networking and Awards Program (Tues.): $95 ❍ Annual Fun Run/Walk (Wed.): $10 (Proceeds go to the Fisher House™) ❍ CEO Circle Session (Wed.): FREE to CEO Circle members; $150 for all other CEOs Total fee for special events $ LAST FIRST MIDDLE NICKNAME (How you would like your first name to appear on your Congress badge) TITLE ORGANIZATION ADDRESS CITY/STATE/ZIP GRAND TOTAL FOR EXTRA ACTIVITIES (Total for Sections 2-6) $ COUNTRY PHONE FAX EMAIL SIX-CHARACTER ID NUMBER from upper left-hand corner of your mailing label Is this your ❍ Home or ❍ Business Address? SECTION 8: ACHE Status/Basic Registration Fee My ACHE status/Congress basic registration fee (for events in Section 1) is: ❍ Member $880 ❍ Nonmember $1,080 ❍ Physician or board member attending with ACHE member $880 ❍ Membership application attached $880 plus membership fee Calculate your fees here Basic registration fee (Section 8) Extra activities fee (total from Sections 3-6) Promotional code: (enter code number and subtract amount) Total Registration Fee Fees $ $ $ $ SECTION 9: Payment Payable in U.S. dollars or equivalent Canadian currency. Purchase orders are accepted from the Department of Veterans Affairs/uniformed services only. ❍ I have enclosed a check made payable to the Foundation of the American College of Healthcare Executives. OR I would like to charge the fees on my: ❍ Visa ❍ MasterCard ❍ American Express ❍ Discover AMOUNT CHARGED ACCOUNT NUMBER EXP. DATE CARDHOLDER'S SIGNATURE OR I am associated with the Department of Veterans Affairs/uniformed services and: ❍ My purchase order is attached. ❍ I will pay on-site. Mail this registration form with your payment to: Foundation of the American College of Healthcare Executives 3376 Eagle Way, Chicago, IL 60678-1033 ✂ To avoid double charges or duplicate registrations, please register using one method only (online, fax or mail). Fax to (312) 424-9405. Fax registrations are only accepted with a credit card payment (Visa, MasterCard, American Express and Discover accounts only). If paying by check, your registration will not be processed until the check has been received. Note: By registering, you agree to permit audio, video and photographic recording of your participation in Congress sessions. Congress Express Registration Form 

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2014 Congress on Healthcare Leadership

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