Sponsor Fall Conference Registration

Please complete this registration form in its entirety. IMPORTANT: After hitting the submit button on this registration form, a confirmation page will appear for you to print and mail in with your check. Your registration is not complete, however, until we receive your payment, which is due by Friday, November 18, 2011.

First Name

Last Name

Title

Organization

Mailing Address

City

State

Zip

Office Phone Number

Email Address

Length of time in your position:Less than a year
4 - 6 years
6 - 10 years
More than 10 years
1 - 3 years

First time conference attendee?Yes
No

I am a Member of:CHPRMS
CSHSMD

I am registering as a:

In which sessions are you most interested?

I would like to attend:

I plan on attending the Newcomer Breakfast on Dec. 7th at 8 am

I would like to renew my membership to:

Any special meal requests?Yes
No

If yes, please indicate:

REGISTRATION INFORMATION

Registration Fee: $350.00 for members only of CHPRMS/CSHSMD. Non-member registration fee is $450. Students may register at a $150.00 rate, however they must present a student ID upon arrival onsite to receive a badge.

NOTE:
• Registration fee refunds will not be given for conference cancellations after November 18, 2011
• Please make every effort to attend if you register. CHPRMS/CSHSMD, 2 non-profit organizations, will still incur cost of an attendee even if a “no-show”
• After registering on-line, you will receive an e-mail receipt. Please print this e-mail receipt and include it with your check.

Payment

Please make check payable to CHPRMS

Mail checks to the attention of:
Amy Hanzel
PO Box 12108
Charlotte, NC 28220
Phone: (803) 412-6742
Email: amy@chprms.com

Hotel Information

The registration deadline for rooms at The Grove Park Inn is Thursday,
November 4, 2011. We have a conference room rate of $159/night + plus
taxes and parking ($20 for overnight, and $10 for one day only). Mention
that you are attending the CHPRMS/CSHSMD conference to receive the
conference rate. Reserve your room by calling: 866-474-1989, or by
visiting The Grove Park Inn website at www.groveparkinn.com. To get the
discounted rate of $159 (not including taxes), you must enter our group
number 068E902.

CHPRMS

Carolinas Healthcare Public Relations & Marketing Society