EmailMe Form - 2017 NCHN Leadership Experience Registration

Registration Fees:

NEW NETWORK LEADER WORKSHOP
Oct. 17, 2017 ($199 for NCHN members; $299 for non-members)

LEADERSHIP FORUM
Oct. 18 & 19, 2017 ($399 for NCHN members; $499 for non-members, $349 for participants of the New Network Leader Workshop)

--->--->Please complete one form per attendee<--<---
______________________________________________________________

Your registration fee(s) includes the following:

>NEW NETWORK LEADER WORKSHOP:
Workshop materials, Networking Lunch, 2 Networking Breaks, and
provides eligibility to register and participate in the 2017 NCHN Leadership Forum.

>LEADERSHIP FORUM:
Workshop materials, 2 Breakfasts, 2 Networking Lunches, 3 Networking Breaks,
Snacks during evening activity, and at least 3 webinars between November
2017 - April 2018 to continue expanding your leadership skills.

First Name *

Last Name *

Title *

Organization *

Mailing Address *

City *

State *

Zip Code *

Phone *

### - ### - ####

Email *

Registrant Category *

NCHN Member

Non-Member

NCHN Staff

Speaker

You may select more than one

I am registering for *

1-day New Network Leader Workshop (Oct. 17th) [$199/NCHN Members, $299 Non-members]

1.5-day Leadership Forum (Oct. 18 & 19) [$399/NCHN Members, $499 Non-members, $349/participant of New Network Leader Workshop]

You may select both.

Payment Information

After your registration form is submitted, you will be directed to our Leadership Experience webpage where you will find a PayPal link to complete your payment with credit card. You will also find the phone # to make your hotel room reservations.

Additional Categories (please check all that currently apply)

Meal Preference (NCHN will accommodate when possible):

Additional Comments & Requests (e.g. seating/viewing needs, questions, etc.)

Optional: Do you have any current leadership concerns, interests, or topics that you would like to see addressed at the New Network Leader Workshop or the Leadership forum?

Notes, Publicity & Cancellation Policy

In submitting this form, I acknowledge that I will be invoiced for the amount due, which is calculated based upon my category of registration (NCHN Member or non-member) and for which day(s) I have registered (New Network Leader Workshop &/or Leadership Forum). By clicking Submit below, I am registering for the 2017 NCHN Leadership Experience and agree to pay the applicable registration fee.

Cancellation Policy: After registering, if you should be unable to attend the 2017 NCHN Leadership Experience, NCHN will refund the registration fee in accordance with the following guidelines: The 2017 NCHN Leadership Experience fee, minus $50 processing charge. Written cancellation must be received by Linda Weiss at lweiss@nchn.org by Tuesday, October 1, 2017. If a cancellation request is received after October 1, 2017, due to commitments to the Hotel, we will be unable to provide a refund. Refunds will be made after the Leadership Experience.

If you should need to cancel after October 1, 2017 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 Linda Weiss at lweiss@nchn.org

Publicity: I give NCHN permission to share my name and contact in a listing of participants with other 2017 NCHN Leadership Experience participants and permission to use my name, likeness, image, voice, and/or appearance in any pictures, photographs, video recordings, audiotapes, digital images, and the like, taken or made in conjunction with NCHN's 2017 Leadership Experience.

I agree that NCHN has complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with NCHN’s mission. These include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, promotional or educational materials in any medium, including, but not limited to a mobile event app and NCHN’s website. This agreement extends to any currently known medium or any medium developed in the future.

I acknowledge that I will not receive any compensation for the use of any of the above and hereby release NCHN, its employees and its agents from any and all claims which arise out of or are in any way connected with such use.

I acknowledge I can deny such permissions by clicking the corresponding statements below.

After clicking the Submit button below, you will be redirected to the 2017 Leadership Experience page of our website where you will find a link to PayPal to pay your registration fee and the number to the hotel to make your room reservations. You will also receive a copy of your registration via email.

Publicity

I deny NCHN permission to share my name and contact information with other NCHN 2017 Leadership Experience Participants

I deny NCHN permission to to use my name, likeness, image, voice, and/or appearance in any pictures, photographs, video recordings, audiotapes, digital images, and the like, taken or made in conjunction with NCHN's 2017 Leadership Experience.