1.5 CEs - Illinois Health Care Association

september 10-13, 2012 l Registration Form
62nd annual Convention & Trade show
Peoria, illinois
TYPE OR PRINT CLEARLY IN ALL TAN SHADED AREAS
FACILITY OR CORPORATE OFFICE
CONTACT PERSON
ADDRESS
CITY STATE ZIP
E-MAIL PHONE FAX
reGisTraTioN Fees EARLY REGISTRATION LATE REGISTRATION
Submitted by August 10 Submitted after August 10
IHCA, ICLTC, or IHA member facility, corporate office, $ 795 online $ 995 online
or group of 2-4 DD 16 and under with same administrator $ 845 fax or mail $1,045 fax or mail
Non-member facility or corporate office (for 1-20 individuals) $1,245 online $1,445 online
$1,295 fax or mail $1,495 fax or mail
Additional registrants (more than 20 individuals)
IHCA individual member, LTCNA member, physician,
$50 per person $60 per person
or administrator/RSD only of ONE 16-bed facility $345 per person $375 per person
TiCkeT FuNCTioNs (Indicate functions each registrant will attend on the next page)
Convention Special Events (Payment can be combined with registration fee)
IHCA Golf Outing (Monday) $145 per person
Ovations (Wednesday Breakfast) $30 per person
Tribute (Wednesday Dinner) $45 per person
Fees include: Admission to educational sessions and the trade show, lunch on Tuesday and Wednesday, and a copy of the
Convention and Trade Show program book.
FYi: Substitute menus for special diets can be arranged through the IHCA office.
Note: The early registration deadline is August 10. A 10% service fee applies to all refunds. NO refunds after August 24.
q Please check here if you would like to contribute to the Maitland/Warner Long Term Care Nurses Scholarship Fund. In the
appropriate area below, identify the amount of your contribution. (For more information on this scholarship, please go to
www.ihca.com) Thank you.
Totals
If any registrant needs special aids or services identified in the Americans with Disibitities Act, q Yes, please contact
please indicate here and a representative of the IHCA Education Department will contact you. q None required
MAIL COMPLETED FORM AND CHECK(S) PAYABLE TO IHCA AND/OR MAITLAND/WARNER SCHOLARSHIP FUND
TO COVER TOTAL PAYMENT OF REGISTRATION FEES AND TICKETS PURCHASED TO:
ILLINOIS HEALTH CARE ASSOCIATION l 1029 S. FOURTH ST. l SPRINGFIELD, IL 62703-2224
CliCk here to register online
REGISTRATION FEE $
CONTRIBUTION TO THE MAITLAND/WARNER SCHOLARSHIP FUND $
SUM OF IHCA TICKETS ORDERED (from reverse side) $
IHCA GOLF TOURNAMENT REGISTRATION FEE (from page 33) $
TOTAL PAYMENT (enclosed) $
For Association Use: DATE IHCA AMOUNT CHECK NO. IHCA-PAC AMOUNT CHECK NO.
Back to cover
43