EmailMe Form - 2022 NCHN Leadership Experience Registration

Registration Fees: Registration fee is for ONE (1) participant only. Additional participants from the same organization must register separately.

NCHN members: $150*
non-members: $250

*NCHN members who register 2 participants receive a complimentary registration for a third network staff to attend.

First Name *

Last Name *

Title *

Organization *

Mailing Address *

City *

State *

Zip Code *

Phone *

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

Email *

Registrant Category
(You may select more than one) *

NCHN Member

Non-Member

NCHN Staff

Additional Categories (please check all that currently apply)

Member of an NCHN Network Member - please provide network name below*

HRSA Staff

HRSA Grantee - please specify program below*

Other - please specify below*

* Please Specify Here

Payment Information

Upon receipt of your registration form, we will send you an electronic invoice via PayPal. You will be able to make a credit card payment directly from the invoice. If you prefer to pay by check, please mail it to:

NCHN
231 NW 53rd Street
Oakland Park, FL 33309

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). By clicking Submit below, I am registering for the virtual, 2022 NCHN Leadership Experience and agree to pay the applicable registration fee.

Cancellation Policy: After registering, if you should be unable to attend the 2022 NCHN Leadership Experience, NCHN will refund the registration fee in accordance with the following guidelines: The 2022 NCHN Leadership Experience fee, minus $25 processing charge. Written cancellation must be received by Linda Weiss at lweiss@nchn.org by Monday, October 10, 2022. If a cancellation request is received after that date, we will be unable to provide a refund.

In the case you are not able to attend after you register, you may substitute a participant. To do so, please email Linda Weiss, lweiss@nchn.org and cc Tara Long, tlong@nchn.org. 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 2022 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 2022 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 you will receive a copy of your registration via email.

Publicity

I deny NCHN permission to share my name and contact information with other NCHN 2022 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 2022 Leadership Experience.