EmailMe Form - 2012 NCHN Leadership Summit Registration Form

First Name *

Last Name *

Title *

Organization *

Mailing Address *

City *

State *

Zip Code *

Phone *

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

Email *

Registrant Category *

NCHN Member ($175)

HRSA/ORHP Network Development Grantee ($250)

Not a NCHN Member ($275)

Wednesday Morning Special Workshop ONLY: $75

Which HRSA/ORHP Network Development Grant program are you involved in?

HRSA Network Development Grant Program

HRSA Network Development Planning Grant Program

HRSA HIT Network Development Grant Program

HRSA Workforce Network Development Grant Program

Special Workshop on Wednesday morning: Strategies for Network Leaders to Partner with Foundations *

I will attend this session ONLY ($75)

I will attend sessions on Tuesday and Wednesday

I will attend sessions on Tuesday, but will NOT be attending this session on Wednesday morning

Additional Comments & Requests (e.g., dietary restrictions, questions, etc.)

Notes & 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 ($175 for NCHN Members, $250 for non-NCHN Members who are HRSA/ORHP grantees in one of the Network Development Programs; and $275 for attendees who are not a member of NCHN or a HRSA Network Development grantee). By clicking Submit below, I am registering for the 2012 NCHN Leadership Summit and agree to pay the applicable registration fee.

Cancellation Policy: If, for some unfortunate reason you should be unable to attend the 2012 NCHN Leadership Summit, after registering, NCHN will refund the registration fee in accordance with the following guidelines: The 2012 NCHN Leadership Summit fee, minus $50 processing charge, will be refunded after the Summit if written cancellation is received by Christy Sullenberger at csullenberger@nchn.org by Tuesday, September 11, 2012. If a cancellation request is received after September 11, 2012, due to commitments to the Hotel, we will be unable to provide a refund.