Conf. Registration Form
Please submit one registration form per person; indicate top session selections(bottom of form); check appropriate registration fee; submit as many copies of the form as needed.

Please note, you can pay online using PayPal once this form has been submitted.

Registration Fees: For groups of 10 or more, please contact jw@nehrsa.org for special pricing. For Non-Member rates please contact the NEHRSA office at 800-228-4772 ext. 115.

If you are a Club Owner and haven’t attended a NEHRSA conference in the last 5 years, be sure to check the appropriate box below, for a chance to win a FREE Guest Room.
Contact Information
First Name:
Last Name:
Information Requested
Club or Organization
Mailing Address
City
State
Zip
Phone
Fax
Email
Attendee Name
Title
Check here if you are a Club Owner and haven't attended a NEHRSA Conference in the last 5 years.
1st Person 1 Day After Oct. 17, 2012 = $229
1st Person 2 Days After Oct. 17, 2012 = $412
2nd - 4th Person 1 Day After Oct. 17, 2012 = $219
2nd - 4th Person 2 Days After Oct. 17, 2012 = $393
5th & Each Additional 1 Day After Oct. 17, 2012 = $209
5th & Each Additional 2 Days After Oct. 17, 2012 = $375
Tuesday Break Out Sessions "A" 1st Choice A-1   A-2   A-3   A-4   A-5  
Tuesday Break Out Sessions "A" 2nd Choice A-1   A-2   A-3   A-4   A-5  
Tuesday Break Out Sessions "B" 1st Choice B-1   B-2   B-3   B-4   B-5  
Tuesday Break Out Sessions "B" 2nd Choice B-1   B-2   B-3   B-4   B-5  
Tuesday Break Out Sessions "C" 1st Choice C-1   C-2   C-3   C-4   C-5  
Tuesday Break Out Sessions "C" 2nd Choice C-1   C-2   C-3   C-4   C-5  
Wednesday Break Out Sessions "D" 1st Choice D-1   D-2   D-3   D-4   D-5  
Wednesday Break Out Sessions "D" 2nd Choice D-1   D-2   D-3   D-4   D-5  
Wednesday Break Out Sessions "E" 1st Choice E-1   E-2   E-3   E-4   E-5  
Wednesday Break Out Sessions "E" 2nd Choice E-1   E-2   E-3   E-4   E-5  
Wednesday Break Out Sessions "F" 1st Choice F-1   F-2   F-3   F-4   F-5  
Wednesday Break Out Sessions "F" 2nd Choice F-1   F-2   F-3   F-4   F-5  
Vegetarian Luncheon
Please indicate your top two preferences for each time slot.
Every Attempt will be made to honor 1st and 2nd choice selections; however, NEHRSA reserves the right to place registrants in third, or an alternative choice if a specified session is full. Some sessions may have space/attendee limitations. Early registration is recommended as requests will be processed on a first-received, first-served basis.

REGISTRATION REFUND POLICY – All conference registration cancellations must be requested in writing. Phone registrations must be guaranteed by a credit card. No-shows will be charged. A 50% refund may be obtained when reservations are cancelled 10 days prior to the event. No refunds will be made after October 9, 2012. Substitutions are allowed.
  

* Bold Fields are Required