NC Community Health Center Association · Patient-Centered ...



North Carolina Community Health Center Association2021 Virtual Primary Care ConferenceApril 7,8, and 9, 2021Organizational PRE-REGISTRATION & Payment FormRegistering Organization: FORMTEXT ????? Organizational Contact?First?Name:? FORMTEXT ?????Organizational Contact?Last Name:? FORMTEXT ?????Organization Address:? FORMTEXT ?????City:? FORMTEXT ?????State:? FORMTEXT ?????Zip:?? FORMTEXT ?????Work Phone:? FORMTEXT ?????Email:? FORMTEXT ?????Organization Type: ? FQHC/CHC? Free/Charitable Clinic? Rural Health Clinic ? OtherIndividual Authorized Registrant Information:NCCHCA will be in contact with each authorized employee with registration and platform access information. Each attendee must register individually for access to virtual event!Please provide complete information for each authorized registrant. Full Conference Registrants are priced as follows: First registrant: $695.00Registrants 2-10: $595.00 eachRegistrant 11 and beyond: $395.00 each.Registrant 1 - $695.00 Registrant 1 $695.00: First Name:? FORMTEXT ?????Last Name:? FORMTEXT ?????Email:? FORMTEXT ?????Title:? FORMTEXT ?????Registrants 2 – 10 - $595.00 Each Registrant 2 $595.00: First Name:? FORMTEXT ?????Last Name:? FORMTEXT ?????Email:? FORMTEXT ?????Title:? FORMTEXT ?????Registrant 3 $595.00: First Name:? FORMTEXT ?????Last Name:? FORMTEXT ?????Email:? FORMTEXT ?????Title:? FORMTEXT ?????Registrant 4 $595.00: First Name:? FORMTEXT ?????Last Name:? FORMTEXT ?????Email:? FORMTEXT ?????Title:? FORMTEXT ?????Registrant 5 $595.00: First Name:? FORMTEXT ?????Last Name:? FORMTEXT ?????Email:? FORMTEXT ?????Title:? FORMTEXT ?????Registrant 6 $595.00: First Name:? FORMTEXT ?????Last Name:? FORMTEXT ?????Email:? FORMTEXT ?????Title:? FORMTEXT ?????Registrant 7 $595.00: First Name:? FORMTEXT ?????Last Name:? FORMTEXT ?????Email:? FORMTEXT ?????Title:? FORMTEXT ?????Registrant 8 $595.00: First Name:? FORMTEXT ?????Last Name:? FORMTEXT ?????Email:? FORMTEXT ?????Title:? FORMTEXT ?????Registrant 9 $595.00: First Name:? FORMTEXT ?????Last Name:? FORMTEXT ?????Email:? FORMTEXT ?????Title:? FORMTEXT ?????Registrant 10 $595.00: First Name:? FORMTEXT ?????Last Name:? FORMTEXT ?????Email:? FORMTEXT ?????Title:? FORMTEXT ????? Registrants 11 or more - $395.00 Each Registrant 11 $395.00: First Name:? FORMTEXT ?????Last Name:? FORMTEXT ?????Email:? FORMTEXT ?????Title:? FORMTEXT ?????Registrant 12 $395.00: First Name:? FORMTEXT ?????Last Name:? FORMTEXT ?????Email:? FORMTEXT ?????Title:? FORMTEXT ?????Registrant 13 $395.00: First Name:? FORMTEXT ?????Last Name:? FORMTEXT ?????Email:? FORMTEXT ?????Title:? FORMTEXT ?????Registrant 14 $395.00: First Name:? FORMTEXT ?????Last Name:? FORMTEXT ?????Email:? FORMTEXT ?????Title:? FORMTEXT ?????Registrant 15 $395.00: First Name:? FORMTEXT ?????Last Name:? FORMTEXT ?????Email:? FORMTEXT ?????Title:? FORMTEXT ?????Registrant 16 $395.00: First Name:? FORMTEXT ?????Last Name:? FORMTEXT ?????Email:? FORMTEXT ?????Title:? FORMTEXT ?????Additional Registrants: $395.00 – please attach on a separate sheet of paper if more than 16.Include Last Name, First Name, Email Address, and Title.Photographic/Video Consent Statement: Registration for attendance or participation in this event and associated activities constitutes an agreement by registrant to permit NCCHCA to use and distribute the registrant or attendee’s image or voice in photographs, videotapes, electronic reproduction, audiotapes, and such events and activities.PAYMENT INFORMATION: Payment by check or money order must accompany registration form. Forms without payment will not be considered. (Credit card payments are accepted online for individual registrations only.)Amount enclosed: $Click here to enter text.Submit Organizational Pre-Registration Form to: NC Community Health Center AssociationATTN: Finance Department4917 Waters Edge Dr., Suite 165Raleigh, NC 27606-2459Office: (919) 469-5701 Fax: (919) 469-1263Cancellation/Refund Policy:Written notice of cancellation must be postmarked by March 31, 2021 for a partial refund, less a $50.00 cancellation fee. No refunds will be given after March 31, 2021; however participant substitutions can be accommodated upon approval up to March 31, 2021. Please allow sixty days post-conference for refunds to be processed.Other Administrative Fees: NCCHCA will charge a $25.00 administrative fee for registrations that have been previously processed and/or require re-submission due to incorrect selection of registration fees or denial of payment for any reason. FOR NCCHCA USE ONLYDate Received: ____________Amount Enclosed: __________ FORMCHECKBOX Check FORMCHECKBOX Money Order ................
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