Conference Materials

To register, call 800-417-2035 • Fax 866-678-5755 or Email: registration@beckershealthcare.com http://www.beckershospitalreview.com/annualmeeting2014.html" Registration form Photocopies are acceptable. Please print or type below. Please use a separate registration form for each attendee. Hospital Review Becker's Hospital Review Annual Meeting May 15-17, 2014 S w i ss o t e l • C h i c a g o , I l l i n o i s Registration information general information First/Last Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ CONTINUING EDUCATION ACHE Degree (As you wish it to appear on your badge): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Title: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Facility/Company: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City/State/Zip: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Phone: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Fax: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Email: ______________________________________________________________________________________________ Registration Fees HOTEL RESERVATIONS Annual Conference & Exhibits Receive multiple registrant discount(s). The more people you send, the greater discount you receive. The prices listed below are per person. Your registration includes all conference sessions, materials and the meal functions. Main Conference only Fees Becker's Healthcare is authorized to award 11.5 hours of pre-approved ACHE Qualified Education credits (non-ACHE) for this program toward advancement, or recertification in the American College of Healthcare Executives. Participants in this program wishing to have the continuing education hours applied toward ACHE Qualified Education credits should indicate their attendance when submitting application to the American College of Healthcare Executives for advancement or recertification. Amount Fees Amount (Before 4/1/14) (After 4/1/14) 1st Attendee $700 $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $800$ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2nd Attendee $675 $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $775$ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3rd Attendee $650 $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $750$ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4th Attendee or more $625 $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $725$ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (Ask about larger group discounts) TOTAL ENCLOSED$ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Payment information q Enclosed is a check, payable to ASC Communications q I authorize to charge my: Check #: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ q q q Printed Cardholder Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Zip Code: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Cardholder Billing Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City/State/Zip: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ CVV#/3-digit #:_ _ _ _ _ _ _ _ _ _ _ _ _ _ Swissotel 323 E. Wacker Drive Chicago, IL 60601 (312) 565-0565 Group Room Rates: $299.00 CONFERENCE QUESTIONS For additional information or questions regarding the conference please contact becker@beckershealthcare.com For Becker's Hospital Review and exhibitor/ sponsorship questions contact 800-417-2035 Becker's Healthcare 800-417-2035 Credit Card Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Expiration Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Swissotel has set aside special group rates for conference attendees. Reservation information coming soon. To Register Complete registration form and mail or fax as follows: Mail: Fax: Call: Email: Web site: Make checks payable to ASC Communications and mail to 315 Vernon Ave., Glencoe IL, 60022 Fax registration form with credit card information to 866-678-5755 Call 800-417-2035 to register by phone registration@beckershealthcare.com www.BeckersHospitalReview.com Cancellation Policy: Written cancellation requests must be received by March. 1, 2014. Refunds are subject to a $100 processing fee. Refunds will not be made after this date. register ONLINE at: www.beckershospital review.com/annual meeting2014.html Multi-Attendee Discount Policy: To be eligible for the discount, your hospital must be registered at one time and work at the same address. Just copy the registration form for each attendee. Employees from a 2nd location are not eligible for the discount. ADA REQUEST If you require special ADA accommodations, please contact us at 800-417-2035 ONLINE REGISTRATION www.beckershospitalreview.com/ annualmeeting2014.html Register before April 1, 2014, and SAVE on registration! For information on exhibiting and sponsorships, call 800-417-2035 Visit www.BeckersHospitalReview.com.

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