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Registration Form, 2011 CA-NV ACHSA Conference (co-hosted by the Institute for Medical Quality)

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Please complete this application, print it, and mail it with your fee to the address below:

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ACHSA/IMQ 2011
PO Box 1511
Folsom, CA 95763

Make checks payable to: CA/NV ACHSA Conference 2011

non-profit Tax ID # 943117900

NEW! If you'd like to register and pay with a credit card, click HERE!

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Registration fees:

• CA-NV ACHSA member: $145.00;
• Non-member: $205.00 (includes one year membership in ACHSA!)
• One day registration: $115.00

Name
Job Title
Affiliation
Daytime Phone No.
Mailing Address
City
State & Zip
Email Address
Check here if a vegetarian diet is required

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Cancellation Policy

Cancellations must be made in writing or faxed by close of business on October 14, 2011 in order to receive a refund minus a $50.00 processing fee. NO REFUNDS wil be made for cancellations after this date; however, substitutions are permitted when the registrant is unable to attend. If paying by purchase order, payment OR proof of purchase order must be received by the registrar prior to the conference start.

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Please Note: Hotel accommodations are not included with conference registration. Please contact the Lion's Gate Hotel, Sacramento directly at (866) 258-5651
Make reservations BEFORE October 14, 2011 to take advantage of special group rates!
Click HERE to book your room online!
Click HERE to book online with a credit card!

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