CAHQ Annual Conference Online Registration Form 2012

2012 CAHQ Spring Conference Online Registration Form
March 20, 2012
at the California Endowment
1000 N Alameda Street
Los Angeles, CA 90012

Name:
Title:
Organization::
Mailing Address:
City
State	Zip This is my: Home Address Work Address

Please check here if you prefer NOT to have your name and contact information published in the Registrant List:
		Daytime Phone
e-mail address

Nursing License #
Other License #
	ADA Requirements:
	Dietary Requirements:

	Tuition:
	CAHQ Members Early Registration (on or before 2/15/2012)........................................		$250
	CAHQ Members Registration (after 2/15/2012)............................................................		$299
	Register and Join Early Registration (on or before 2/15/2012)........................................		$375
	Register and Join (registration after 2/15/2012)............................................................		$425
	Non-Members..........................................................................................................		$450
	A $25 Processing fee will be charged if rebilling of a credit card is necessary
	A $75 Processing fee will apply to all refund requests

CAHQ, 4570 Van Nuys Blvd. # 326, Sherman Oaks, CA 91403

For more information, contact CAHQ at 562-212-1067