Becker's Hospital Review

REGISTRATION FORM Photocopies are acceptable. Please print or type below. Please use a separate registration form for each attendee. REGISTRATION FEES 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 AMOUNT FEES AMOUNT (Before 4/1/15) (After 4/1/15) 1st Attendee $750 $ _______________ $850 $ _______________ 2nd Attendee $725 $ _______________ $825 $ _______________ 3rd Attendee $700 $ _______________ $800 $ _______________ 4th Attendee or more $675 $ _______________ $775 $ _______________ (Ask about larger group discounts) TOTAL ENCLOSED $ _______________ PAYMENT INFORMATION q Enclosed is a check, payable to ASC Communications Check #: __________________ q I authorize to charge my: q q q Credit Card Number: _______________________________________ Expiration Date: _____________________ Printed Cardholder Name: __________________________________ Zip Code: ___________________________ Cardholder Billing Address: ________________________________________________________________________ City/State/Zip: ____________________________________________________________________________________ Signature: __________________________________________________________ CVV#/3-digit #: _____________ CONTINUING EDUCATION ACHE Becker's Healthcare is authorized to award 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. HOTEL RESERVATIONS Swissôtel has set aside special group rates for conference attendees. To make a reservation, please visit: https://resweb.passkey.com/go/bhr2015 Swissôtel 323 E. Wacker Drive Chicago, IL 60601 (312) 565-0565 Group Room Rates: Pricing starts at $269.00 CONFERENCE QUESTIONS For additional information or questions regarding the conference please contact lgroeper@beckershealthcare.com For Becker's Hospital Review and exhibitor/ sponsorship questions contact 800-417-2035 Becker's Healthcare 800-417-2035 ADA REQUEST If you require special ADA accommodations, please contact us at 800-417-2035 ONLINE REGISTRATION https://www.regonline.com/ hospitalreview6thannualmeeting Register before April 1, 2015, and SAVE on registration! For information on exhibiting and sponsorships, call 800-417-2035 GENERAL INFORMATION REGISTRATION INFORMATION First/Last Name: ____________________________________________________________________ Degree (As you wish it to appear on your badge):______________________________________________________ Title: _______________________________________________________________________________________________ Facility/Company: __________________________________________________________________________________ Address:____________________________________________________________________________________________ City/State/Zip: ______________________________________________________________________________________ Phone: __________________________________ Fax:_____________________________________________________ Email: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Visit www.BeckersHospitalReview.com. 153 GREAT HOSPITAL AND HEALTH SYSTEM EXECUTIVES SPEAKING MAY 7-9, 2015 • SWISSÔTEL • CHICAGO, ILLINOIS TO REGISTER, CALL 800-417-2035 • FAX 866-678-5755 OR EMAIL: registration@beckershealthcare.com https://www.regonline.com/hospitalreview6thannualmeeting REGISTER ONLINE AT: https://www.regonline. com/hospitalreview 6thannualmeeting 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. TO REGISTER COMPLETE REGISTRATION FORM AND MAIL OR FAX AS FOLLOWS: Mail: Make checks payable to ASC Communications and mail to 315 Vernon Ave., Glencoe IL, 60022 Fax: Fax registration form with credit card information to 866-678-5755 Call: Call 800-417-2035 to register by phone Email: registration@beckershealthcare.com Web site: www.BeckersHospitalReview.com Cancellation Policy: Written cancellation requests must be received by March. 1, 2015. Refunds are subject to a $100 processing fee. Refunds will not be made after this date. Hospital Review Becker's Hospital Review Annual Meeting

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