2010 Annual Conference Registration Form

Name

Title

Discipline

Administrative/Clerical Administrator/CEO Bereavement Coordinator Business Office/Billing CNA Chaplain/Minister Home Health Aide Human Resources MD Marketing/Outreach MSW/BSW/LMSW Nurse Practitioner Patient Care Coordinator Pharmacist QI/PI RN/LPN Volunteer Volunteer Management Other

Phone

Email Address - This is needed to send confirmation to.

Additional Email Address - OPTIONAL - This email address will also receive the initial confirmation notice that is sent when you submit this form.

Agency Name (if you are not with an agency, just type None)

CA

Address

Address2

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

I have attended a clinical conference with The Carolinas Center before

Yes No

How Many?

0 1 2 3 4 5 6 7 8 9 10 More than 10

Please let us know if you require special services to fully participate in this program.

Please choose from one of the membership categories below:

If your hospice is a Hospice Provider/Associate Member - choose one of these options:

Full Conference Early Registration $375 (by 8/13/10) Full Conference Regular Registration $445 (after 8/13/10) Full Conference Late/On Site Registration $525 (on/after 9/24) Pre-Conference Only Early Registration $85 (by 8/13/10) Pre-Conference Only Regular Registration $95 (after 8/13/10) Pre-Conference Only Late/On Site Registration $105 (on/after 9/24/10) Full Conference Including Pre-Conference Early Registration $400 (by 8/13/10) Full Conference Including Pre-Conference Regular Registration $480 (after 8/13/10) Full Conference Including Pre-Conference Late/On Site Registration $560(after 9/24/10) Daily Rate Early Registration $215 (by 8/13/10) Daily Rate Regular Registration $225 (after 8/13/10) Daily Rate Late/On Site Registration $235 (on/after 9/24/10)

If you are an Individual Member - choose one of these options:

Full Conference Early Registration $385 (by 8/13/10) Full Conference Regular Registration $455 (after 8/13/10) Full Conference Late/On Site Registration $535 (on/after 9/24) Pre-Conference Only Early Registration $95 (by 8/13/10) Pre-Conference Only Regular Registration $105 (after 8/13/10) Pre-Conference Only Late/On Site Registration $115 (on/after 9/24/10) Full Conference Including Pre-Conference Early Registration $410 (by 8/13/10) Full Conference Including Pre-Conference Regular Registration $490 (after 8/13/10) Full Conference Including Pre-Conference Late/On Site Registration $570(after 9/24/10) Daily Rate Early Registration $225 (by 8/13/10) Daily Rate Regular Registration $235 (after 8/13/10) Daily Rate Late/On Site Registration $245 (on/after 9/24/10)

If you are a Non-Member - choose one of these options:

Full Conference Early Registration $545 (by 8/13/10) Full Conference Regular Registration $595 (after 8/13/10) Full Conference Late/On Site Registration $675 (on/after 9/24) Pre-Conference Only Early Registration $115 (by 8/13/10) Pre-Conference Only Regular Registration $125 (after 8/13/10) Pre-Conference Only Late/On Site Registration $135 (on/after 9/24/10) Full Conference Including Pre-Conference Early Registration $580 (by 8/13/10) Full Conference Including Pre-Conference Regular Registration $640 (after 8/13/10) Full Conference Including Pre-Conference Late/On Site Registration $715(after 9/24/10) Daily Rate Early Registration $315 (by 8/13/10) Daily Rate Regular Registration $325 (after 8/13/10) Daily Rate Late/On Site Registration $335 (on/after 9/24/10)

If coming for one day, please tell us which day you will attend:

Monday Tuesday Wednesday

Will you attend the Opening Reception and Transformation Art Exhibit?

Yes No

Please select the workshops you would like to attend for each session:

Session A

None 1 2 3 4 5 6

Session B

None 1 2 3 4 5 6

Session C

None 1 2 3 4 5 6

Session D

None 1 2 3 4 5 6

Session E

None 1 2 3 4 5 6

Session F

None 1 2 3 4 5 6

Session G	None 1 2 3 4 5 6

Please indicate if you are taking any of the Pre-Conference Sessions:

PC-1 PC-2 PC-3

Would you like to attend the FREE Sunday Medicare Update session:

Yes No

*How would you like to pay?

Visa Master Card Discover Card Purchase Order Number Bill Me

If paying by credit card, please include your card number in this field.

Expiration Date

Three Digit Security Code on Back of Credit Card:

Name on credit card:

If paying with a Puchase Order, please type in the number here:

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