2017 KY Nurses Association Convention
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
<strong>2017</strong> Kentucky <strong>Nurses</strong> <strong>Association</strong><br />
KENTUC<strong>KY</strong> NURSES ASSOCIATION<br />
<strong>2017</strong> EDUCATION SUMMIT REGISTRATION FORM<br />
Thursday, November 2, <strong>2017</strong><br />
Louisville Marriott East<br />
REGISTER ONLINE AT:<br />
1903 Embassy Square Blvd.<br />
www.Kentucky-<strong>Nurses</strong>.org Louisville, <strong>KY</strong> 40299<br />
Name_________________________________________ Credentials __________________<br />
Address ________________________________________RN License No.______________<br />
City __________________ State __________ Zip __________Home Phone_____________<br />
Employer _____________________________________Work Phone ___________________<br />
*If student, please list School of Nursing ________________________________________<br />
E-mail _____________________________ Do you request vegetarian meals?____________<br />
(Required to Complete Registration)<br />
CHECK ONE<br />
Total Enclosed<br />
Registration Fee<br />
CATEGORY<br />
Early Bird<br />
Postmarked by<br />
Mon. Sept. 25<br />
Regular<br />
Postmarked by<br />
Tues. October 24<br />
On-Site<br />
After Tues.<br />
October 24<br />
KNA Member (Lunch and C.E.’s) $75 $95 $105<br />
Non-KNA Member (Lunch and C.E.’s)<br />
Healthcare worker<br />
$110 $120 $130<br />
Student (Lunch and No C.E.’s) $25 $30 $35<br />
General Public (No Lunch and No<br />
C.E.’s) Non Healthcare worker<br />
$50 $50 $50<br />
Select Payment Type:<br />
Check or Money Order (Make check Payable to: Kentucky <strong>Nurses</strong> <strong>Association</strong>)<br />
Visa MasterCard Discover<br />
Account #________ - ________ - ________ - ________ Expiration Date_______/_______<br />
Signature _______________________________________/3 - 4 digit CVV Code________<br />
(Required for Credit Card Payments)<br />
Online: Before October 24 at www.kentucky-nurses.org<br />
By Phone: 502-245-2843 (Credit Card Only)<br />
By Fax: 502-245-2844 (Credit Card Only)<br />
By Mail: Send completed Registration Form with check or credit card information to:<br />
Kentucky <strong>Nurses</strong> <strong>Association</strong>, 305 Townepark Circle Suite 100, Louisville, Kentucky 40243.<br />
Questions: admin@Kentucky-<strong>Nurses</strong>.Org<br />
$20 discount if registering for both Louisville and Lexington Events (both registration forms must be sent in same envelope).<br />
KNA Member Discount: Complete membership form and return with registration to receive KNA member discount.<br />
If you need assistance with registration fees, call KNA.<br />
Refund Policy: Cancellations received prior to Tues. Oct. 24 will receive 50% refund. No cancellation refund after Oct 24<br />
26
Change language