National Health Policy Conference Organizational Affiliate Registration Form February 9–10, 2015 | Renaissance Washington, D.C. Step 1. Provide Registrant Information Step 3. Add an Adjunct or Interest Group Meeting Please type or print complete information Adjunct/Interest Group Meetings (free; pre-registration is required) Last name Meet the Experts Student Breakfast (2/9) • 8:00–9:00 a.m. Health Workforce IG Breakfast (2/9) • 7:30–9:00 a.m. Disparities IG Happy Hour (2/9) • 7:00–8:30 p.m. r r r Joint Public Health, Advocacy, Translation & Communications IG Breakfast (2/10) • 7:30–8:45 a.m. r First name as you’d like it to appear on badge: State Health Research & Policy IG Breakfast (2/10) 7:00–8:45 a.m. r Prefix First name r Same as above r Other Step 4. Note Special Requests Degree(s) Department Organization name Primary address Please contact specialneeds@academyhealth.org to discuss any special needs and accessibility questions. Step 5. Calculate Your Payment City State/Province 2 Accessibility: R Dietary: r vegetarian meals r vegan meals r gluten-free meals r kosher meals r other ____________________ Job title Zip/Postal code Country r Original purchase order or check payable to AcademyHealth enclosed. Faxed purchase orders and copies of checks will not be processed. AcademyHealth’s tax ID number is 52-1260918. r Please charge my credit card r Visa r MasterCard r Discover r American Express Phone Email Assistant’s email (optional) Primary Field r Clinical Practice r Health Policy r Health Care Administration r Health Services Research Conference $___________ 900.00 Adjunct Meetings $___________ 0.00 900.00 Total Amount Due $___________ r Teaching r Other Credit Card# Exp. DateSecurity Code Cardholder Name: Step 2. Select Conference Registration Rate Conference Registration Photo Release Organizational Affiliate Early, by Dec. 19 r $900 Standard, by Jan. 30 r $1,000 On-site r $1,050 Organizational Affiliate Code: Signature: From time to time we use photographs of conference participants in our promotional materials. By virtue of your attendance at the 2015 National Health Policy Conference, AcademyHealth reserves the right to use your likeness in such materials. 1150 17th Street, NW, Suite 600 Washington, DC 20036 Tel: 202-292-6700 Fax: 202-292-6891 www.academyhealth.org/nhpc/register