HBA 2012 Leadership Conference Registration Form

HBA 2012 Leadership Conference Registration Form

Early Bird Full Conference– until Friday September 28, 2012

____$1,110 – Member ____$1,340 – Non-member

____$1,040 – Member Group Rate* ____$1,270 – Non-Member Group Rate*

Full Conference – afterFriday, September 28, 2012

____$1,620 – Member ____$1,890 – Non-member

____$1,550 – Member Group Rate* ____$1,820 – Non-Member Group Rate*

Wednesday Evening Pass

____$130 – Member ____$155 – Non-member

Thursday Day Pass

____$710 – Member ____$780 – Non-member

Friday Day Pass

____$365 – Member ____$410 – Non-member

*Groups of five or more are eligible for a discountedregistration rate providing that all five are from the same company and register at the same time.

**Name: ______Title:

**Company: ______Address:

**City: ______**State:______Zip:

**Tel #:**E-mail:

Please choose a 1st, 2nd3rdChoice for all Workshop Sessions

Getting a Seat at the Table: How Women in Healthcare Can Land the Leadership Role They Want

Getting a Seat at the Table: How Women in Healthcare Can Land the Leadership Role They Want

Coaches, Mentors & Sponsors: Why You Need This Trio on Your Professional Journey to the Summit

Finding Your Leadership Voice: The Role of InfluenceFULL

**Attendee name and company affiliation are provided as the registration list:

It's okay to include my informationPlease do not include my information

**Is this your first time attending the HBA Leadership Conference?Yes No

**Are you a current or past HBA Rising Star Recipient?Yes No

**Do you plan to attend our Wed. night reception at 7:00pm (Nov. 7th)?YesNoNot Sure

**Do you want to register for the exclusive Executive Reflections session at 7:30 AM on Friday, November 9? (No additional charge, but limited seating)Yes No

**Are you paying for this conference yourself or will you expense the registration to your company?

MyselfCompany Partial Company Reimbursement

Do you have any of the following dietary needs? Vegetarian Vegan Kosher Gluten Free

***Once completed please fax back to the HBA office at 973.575.1445***

If paying by check, please make check payable to HBA and mail with completed form to: HBA, 373 Route 46 West, Bldg. E., Suite 215, Fairfield, NJ 07004. Forms will not be processed until payment is received.

Amount to be charged

(Circle one) American Express Visa Master Card Check #

Credit Card # ______Expiration Date:

Name on card______***Signature:

Billing Address (if different from above)

______

City: ______State: ______Zip: ______

Requests for refunds must besubmitted in writingto ; refund dependent on timing: submit prior to October 9th for a 100% refund, October 10th – October 29th for a 60% refund. No refunds will be given for any cancellations including those that may be weather-related after October 29th. After this date you will be responsible for the full registration fee.

**This information is required to process the registration form.

**Signature is required to authorize credit card payment, and authorizes the HBA to charge the correct fees if miscalculated by registrant.