Kentucky Nurses Association Convention - 2014

2014 Kentucky Nurses Association
KENTUCKY NURSES ASSOCIATION
2014 CONVENTION REGISTRATION FORM
October 9 – 10, 2014
Holiday Inn Louisville East
1325 S. Hurstbourne Parkway
REGISTER ON LINE AT: Louisville, Kentucky 40222
www.Kentucky-Nurses.org (502) 426-2600
Name____________________________________________________________ Credentials ________________________________
Address ____________________________________________________________________________________________________
City ________________________________________________________ State ____________ Zip__________________________
Home Phone ____________________ Work Phone ___________________ E-mail _______________________________________
Employer ________________________________________________ RN/LPN License # (For CE) __________________________
Student** YES NO School of Nursing __________________________________________________________________
KNA Member: Chapter. ______________________________________________ ANA Member in Other State (Name ) _________
First KNA Convention as Member: YES NO New KNA Member (1 st Year) New Graduate – Date _______________
Do you need any specific accommodations or assistance due to disability? If yes, please explain ______________________________
Do you request vegetarian meals?________
(Required Yes or No)
Are you interested in serving on the Events Planning Committee? ________________
Pre-Registration By: September 12, 2014
Late Registration Begins: September 13, 2014
Check
One
CATEGORY
PRE-REGISTRATION
POST-MARKED BY 9/12/14
Total
Convention
(Circle One)
Daily Rate
(Circle One)
REGISTRATION
POST-MARKED AFTER
9/13/14
Total
Convention
(Circle One)
Daily Rate
(Circle One)
ON-SITE REGISTRATION
RATES APPLY ON 10/8/14
Total
Convention
(Circle One)
Daily Rate
(Circle One)
KNA Member $225.00 $150.00 $250.00 $160.00 $300.00 $200.00
KNA Special $175.00 $130.00 $200.00 $130.00 $250.00 $180.00
Member (Retired)
Non-Member* $300.00* $275.00* $350.00* $290.00* $350.00* $300.00*
Student $35.00** $35.00**
Poster Presenters $70.00*** $70.00***
*Complete a membership form and return to KNA by October 1, 2014 and attend the convention as a new member at the
member rate.
**Student Rate is $35.00 per day. Student rate applies to anyone who is currently enrolled in a Nursing Program. Late fee
applies after October 7, 2014.
***Poster Presenters: Registration fees for Thursday of the convention is $70 and participants must register in advance.
Students register at student rate of $35.
Entire Convention $ Select Payment Type: Check (Make check Payable to: Kentucky Nurses
Association)
Thursday Only $
Visa MasterCard Discover American Express
Student Poster Presenter $
Account # ____________ - ____________ - ____________ - ____________
Non-Student Poster Presenter $
Expiration Date ________/___________ CIV # ______________________
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