NHPCO 11th Clinical Team Conference - (Page 33)
Side 1
ATTENDEE REGISTRATION FORM
NHPCO’s11th ClinicalTeamConferenceandPediatricIntensive
Preconference Seminars September 11-12, 2010 • Main Conference September 13-15, 2010 • Omni Hotel at CNN Center • Atlanta, GA
(Please type or print clearly. Use a separate form for each registrant; copy as needed.)
Attendee Name ________________________________________________________________________ Credentials (RN, LCSW, etc.) __________________________ Organization __________________________________________________________________________ NHPCO Member # ____________________
K
Non-Member
Address ____________________________________________________________City ________________________________State ____________ Zip ________________ Phone ______________________________________Fax ____________________________________ Email
______________________________________
K
First-time CTC Attendee
K
I require special services to fully participate in the conference (please attach a description of your needs)
To register, make your selections in the boxes below. Be careful to note seminars/sessions that may coincide. Only one selection should be made for each Preconference time slot. Please be sure to complete both sides of this registration form.
Registration Form must be faxed/postmarked by these dates in order to receive discounted pricing: Only one selection should be made for each Preconference time slot.
A Main Conference Registration
Monday, Sept. 13 - Wednesday, Sept. 15
Advance
6/12-8/25/2010
MEMBER NONMEMBER
Onsite
After 8/25/2010
MEMBER NONMEMBER
F Preconference Seminars
Two-Day Seminar (see page 7 for MDP Course information)
Hospice MDP Foundational Course Saturday-Sunday, Sept. 11-12 • 8:30 am-5:00 pm
Advance
6/12-8/25/2010
MEMBER NONMEMBER
Onsite
After 8/25/2010
MEMBER NONMEMBER
K $500 K $700 K $670 K $870
$
Subtotal Section A
K $395 K $595 K $470 K $670
(For registrants attending 1-2 days of conference; Fee includes educational sessions on the day(s) selected.) Check the day(s) you will attend.
Full-Day Seminars - Sunday, Sept. 12 • 9:00 am - 5:00 pm (see page 10 for Seminar descriptions)
PC01 - Advance Pain Management PC02 - Management Interpersonal Conflict PC03 - The New Regulatory Environment
B One Day Registration
Check the day you will attend.
Advance
6/12-8/25/2010
MEMBER NONMEMBER
Onsite
After 8/25/2010
MEMBER NONMEMBER
K $225 K $300 K $300 K $375 K $225 K $300 K $300 K $375 K $225 K $300 K $300 K $375 K FREE
Monday, September 13 (Day 1) Tuesday, September 14 (Day 2) Wednesday, September 15 (Day 3)
K $250 K $350 K $350 K $450 K $250 K $350 K $350 K $450 K $195 K $295 K $295 K $395
$
FREE One-Day Seminar - Sunday, Sept. 12 • 9:00 am - 5:00 pm (see page 9 for Seminar description)
PC04 - We Honor Veterans - Train-the-Trainer
Half-Day Seminars - Sunday, Sept. 12 (see page 14 for Seminar descriptions)
9:00 am –Noon PC05 - Death is a Given
Subtotal Section B
For guests of Main Conference registrants only.
K $95 K $95 K $95 K $95
K $170 K $170 K $245 K $170 K $170 K $245 K $170 K $170 K $245 K $170 K $170 K $245
$
C Conference Guest Pass (Does not include Educational Sessions)
(See page 32 for details on Guest Pass)
1:45 pm-4:45 pm (select one seminar for this time slot) PC06 - Hospice Care in the Nursing Home PC07 - Comprehensive IDT Assessment PC08 - Ethics for Hospice Managers (MDP Level l)
Monday, Sept. 13 - Wednesday, Sept. 15 - K $175 Guest Name:
Subtotal Section C
$
Subtotal Section F
D FHSSA IMPACT Fund Event
Special Event – Tuesday, September 14 (See page 5 for full details) I look forward to attending the event: K $60 with Main Conference Registration K $75 without Main Conference Registration K $125 (Patron) (includes admission and acknowledgement for additional support)
G Continuing Education (Please Select CE Type)
(See page 8 for for CE/CME information.)
Counselor K $40
Nurse K $40
Physician K $40
Social Worker
K $40
Subtotal Section G
$
K I will be bringing #______of guests (please provide total # of guests) enclosed is an additional $________ ($60/person) K I cannot attend, but please accept my donation to the
FHSSA IMPACT Fund for $_________.
Contact or Donor Name Address Phone Email
H TOTALS FOR THIS ATTENDEE
Section A (Main Conference) Subtotal for this attendee Subtotal Sections B, C, D, F, G (if applicable) TOTAL for this Attendee (TRANSFER TO “SIDE 2”)
$ ALL registrants please use “Side 2” for payment. Main Conference registrants using the Team Registration Discount can apply the group discount in the Team Registration Discount box.
$
$ $
Subtotal Section D
Please check box to pre-register for lunch. Lunch cannot be guaranteed unless you pre-register!
E Complimentary Boxed Lunch • Monday, Sept. 13, 11:45am-1:30pm
FREE to all registered CTC10 attendees (must check box)
K FREE
33
Table of Contents for the Digital Edition of NHPCO 11th Clinical Team Conference
NHPCO 11th Clinical Team Conference
Contents
Conference Overview
Conference Logistics
General Information
Conference Highlights
Education Highlights
Continuing Education and Evaluation
Special Preconference Events
Preconference Seminars
Plenary Sessions
Concurrent Sessions
Posters
Agenda-at-a-Glance
General Registration Information
Registration Form
Exhibitor Information
Future NHPCO Conference Dates and Locations
NHPCO 11th Clinical Team Conference
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