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
Thursday,AMNov 8, 2012 / Workshops (11:00am – 12:30pm):
Harnessing the Increasing Influence of Patient and Professional Advocacy Groups
Courageous Coaching: It’s Not Easy, It’s Your Job
Extraordinary Female Leadership: Vision is the Differentiator
The Improvisation Edge: Women and Executive Presence
Personalized Medicine – Implications for the Healthcare Ecosystem
The Power of a Story: How to Use Storytelling to Captivate, Persuade and EnrollFULL
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 SummitPitfalls and Possibilities in Today’s Health Policy Environment
Leading Global Matrix Teams: Fostering Open Dialogue and Success
Calm Your Inner Critic and Strengthen Your Inner Coach
Thursday,PM
Nov 8, 2012 / Workshops (3:00 – 4:30pm):
Harnessing the Increasing Influence of Patient and Professional Advocacy Groups
Courageous Coaching: It’s Not Easy, It’s Your Job
Extraordinary Female Leadership: Vision is the Differentiator
The Improvisation Edge: Women and Executive Presence
Personalized Medicine – Implications for the Healthcare Ecosystem
The Power of a Story: How to Use Storytelling to Captivate, Persuade and EnrollFULL
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
Pitfalls and Possibilities in Today’s Health Policy EnvironmentLeading Global Matrix Teams: Fostering Open Dialogue and Success
Calm Your Inner Critic and Strengthen Your Inner Coach
Friday,AM
Nov 9, 2012 / Workshops (9:00 – 10:30am):
Harnessing the Increasing Influence of Patient and Professional Advocacy Groups
The Charisma Edge: Nine Levers for Turning On Your Leadership PowerFULL
Extraordinary Female Leadership: Vision is the Differentiator
Personalized Medicine – Implications for the Healthcare Ecosystem
The Power of a Story: How to Use Storytelling to Captivate, Persuade and Enroll
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
Becoming a Change Leader (Yes, You!): What You Need to Lead Your Organization to Achieve Its Change GoalsLeading Global Matrix Teams: Fostering Open Dialogue and Success
Calm Your Inner Critic and Strengthen Your Inner Coach
Friday,PM
Nov 9, 2012 / Optional: Bonnie St. John Seminar(2:30 – 4:00pm)$75.00:
High Performance Resilience for Leaders
**Attendee name and company affiliation are provided as the registration list:
It's okay to include my informationPlease 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)?YesNoNot 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?
MyselfCompany 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.