Document 6576572

National Health Policy
Conference
Organizational Affiliate
Registration Form
February 9–10, 2015 | Renaissance Washington, D.C.
Step 1. Provide Registrant Information
Step 3. Add an Adjunct or Interest Group Meeting
Please type or print complete information
Adjunct/Interest Group Meetings (free; pre-registration is required)
Last name
Meet the Experts Student Breakfast (2/9) • 8:00–9:00 a.m.
Health Workforce IG Breakfast (2/9) • 7:30–9:00 a.m.
Disparities IG Happy Hour (2/9) • 7:00–8:30 p.m.
r
r
r
Joint Public Health, Advocacy, Translation
& Communications IG Breakfast (2/10) • 7:30–8:45 a.m.
r
First name as you’d like it to appear on badge:
State Health Research & Policy IG Breakfast (2/10) 7:00–8:45 a.m.
r
Prefix
First name
r Same as above
r Other
Step 4. Note Special Requests
Degree(s)
Department
Organization name
Primary address
Please contact
specialneeds@academyhealth.org
to discuss any special needs and
accessibility questions.
Step 5. Calculate Your Payment
City
State/Province
2 Accessibility:
R
Dietary:
r vegetarian meals
r vegan meals
r gluten-free meals
r kosher meals
r other ____________________
Job title
Zip/Postal code
Country
r Original purchase order or check payable to AcademyHealth enclosed. Faxed purchase orders and copies of checks will not be processed.
AcademyHealth’s tax ID number is 52-1260918.
r Please charge my credit card
r Visa
r MasterCard
r Discover
r American Express
Phone
Email
Assistant’s email (optional)
Primary Field
r Clinical Practice
r Health Policy
r Health Care Administration r Health Services Research
Conference $___________
900.00
Adjunct Meetings
$___________
0.00
900.00
Total Amount Due
$___________
r Teaching
r Other
Credit Card#
Exp. DateSecurity Code
Cardholder Name:
Step 2. Select Conference Registration Rate
Conference Registration
Photo Release
Organizational Affiliate
Early, by Dec. 19
r $900
Standard, by Jan. 30
r $1,000
On-site
r $1,050
Organizational Affiliate Code:
Signature:
From time to time we use photographs of conference participants in
our promotional materials. By virtue of your attendance at the 2015
National Health Policy Conference, AcademyHealth reserves the
right to use your likeness in such materials.
1150 17th Street, NW, Suite 600
Washington, DC 20036
Tel: 202-292-6700 Fax: 202-292-6891
www.academyhealth.org/nhpc/register