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 One reasonable registration price - come for as much of the conference as you would like! Receive multiple registrant discounts. 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 3/1/16) (After 3/1/16) 1st Attendee $850 $ ______________ $950 $ ______________ 2nd Attendee $825 $ ______________ $925 $ ______________ 3rd Attendee $800 $ ______________ $900 $ ______________ 4th Attendee or more $775 $ ______________ $875 $ ______________ (Ask about larger group discounts) TOTAL ENCLOSED_ _ _ _ _ _ _ _ $ PAYMENT INFORMATION c Enclosed is a check, payable to ASC Communications Check #:__________ c I authorize to charge my: c c c 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 up to 18.5 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 Hyatt Regency has set aside special group rates for conference attendees. To make a reservation, please visit: https://aws.passkey.com/ event/13937573/owner/2135/home Hyatt Regency 151 E. Wacker Drive Chicago, IL, 60601 (312) 565-1234 Group Room Rates: Pricing starts at $229.00 CONFERENCE QUESTIONS For additional information regarding the conference, exhibiting or sponsoring please contact: Becker's Healthcare Phone: (800) 417-2035 Fax: (866) 678-5755 Email: registration@beckershealthcare. com ADA REQUEST If you require special ADA accommodations, please contact us at 800-417-2035 ONLINE REGISTRATION www.beckershospitalreview.com/ annualbhr Register before March 1, 2016, and SAVE on registration! 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: _______________________________________________________________________________________ One reasonable price - Come for as much of the conference as you would like! APRIL 27-30, 2016 • HYATT REGENCY • CHICAGO, ILLINOIS TO REGISTER, CALL 800-417-2035 • FAX 866-678-5755 • EMAIL: registration@beckershealthcare.com www.beckershospitalreview.com/annualbhr REGISTER ONLINE AT: www.beckershospitalreview. com/annualbhr 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 second 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: registration form with credit card information to 866-678-5755 Call: 800-417-2035 to register by phone Email: registration@beckershealthcare.com www.BeckersHospitalReview.com Cancellation Policy: Written cancellation requests must be received within 120 days of transaction or by March 1, 2016, whichever is first. Refunds are subject to a $100 processing fee. Refunds will not be made after this date. BECKER'S HOSPITAL REVIEW Becker's Hospital Review Annual Meeting

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