Page 24 - 2014 NECHA E-Brochure

AnnualMeeting(paper)REGISTRATION FORM Today’s Date: ____________ Or Register online - click here
NEW ENGLAND COLLEGE HEALTH ASSOCIATION
October 29-31 Wentworth by the Sea New Castle, NH
____________________________________________________________________________________________
Last Name: First:
Position Title: _____________________________________________________________ Institution/Organization: ____________________________________________________ Mailing Address: ____
City: _____________________________ State: ________ Zip: ____________________ Phone: _(_____)___________________ Email: ____________________________________
*
CE fees included in Registration
~
Registration fees independent of ACHA Membership status
*
Preferred Degree:
REGISTRATION
Full 3-Day registration
Single Day, Wednesday
Single Day, Thursday
Single Day, Friday
Student, FT Undergraduate
(include copy of student ID)
Student, FT Undergraduate Single Day: ____________ (include copy of student ID)
Thru - Oct. 15
___ $355
___ $180
___ $180
___ $150
___ $110
___ $55
Oct. 16 – 28
Check the
following as they apply:
 First time attendee Yes, sign me up as
a room monitor.
Wednesday Evening Soirée
Guest or Single Day Tickets:
__# tickets x $45 each = $_______
Three day registrants, your registration includes a ticket to the Soirée.
On-Site
___ $395
___ $205
___ $150
___ $110
___ $55
___ $400 ___ $205
___ $205
___ $205 ___ $160 ___ $110 ___ $55
TOTAL FEES: $____________
Please circle the workshops/concurrents you plan to attend. Your selections are not binding.
PAYMENT METHOD. 3 OPTIONS:
1)  Check enclosed (payable to NECHA) Ck #___________
2)  Purchase Order (enclosed) PO #________________
3)  Credit Card Option, payment through PayPal. Registrants choosing this option will be sent an invoice via email that will direct them to the PayPal payment site.
Name of person who will process credit card payment:
Self; email address above.
Other Name/Email: ______________________________________________
Pre-Mtg Workshops:
PM1 2 3 4 Wednesday Concurrents:
A123456
B123456 Thursday Concurrents: C123456
D123456 E123456
F123456 Friday Concurrents: G1234567
H123456
A $50 cancellation fee will apply to registrants who give notice prior to October 25. Refunds will not be granted after that date.
SEND YOUR COMPLETED REGISTRATION FORM TO:
NECHA2014 ANNUAL MEETING
741 Hand Road No. Ferrisburgh, VT 05473
Fax: 802 425-5507
□ If you require special accommodations or have additional needs in order to participate, please check this box. Indicate your requests in writing and include with your registration form.
QUESTIONS? Contact Julie Basol, Administrative Director 802.598.7424 [email protected]