WHA Conference 2011 Registration Form

Full Name:
First Name (for badge):
Title:
Address:
City:
State:
Zip:
Institution:
Email Address:

Registration Fees

Registration	$200.00
Non-member Registration	$300.00
Auxilian Registration	$40.00
Awards Banquet/Enterainment	$30.00
3 ACHE Category 1 Credit Hours	$150.00
	Total:

Additional Information

Hospital Preparedness Contact

I will be attending the CEO breakfast Friday morning

I will be taking the trolley tour of Wyoming Medical Center and Elkhorn Rehabilitation Hospital

I will be attending the WONE breakfast

"Member" registration is available only to those persons employed by an institution that is a member of the Wyoming Hospital Association. Advanced registration
will be accepted by FAX, mail, online or by phone until September 16, 2011. After that date, a late registration fee of $20.00 will be assessed.

**Cancellation Policy: Registration fees are non-refundable unless WHA receives notice of cancellation by September 16, 2011. This applies to telephone/FAX registrations as well. You will be billed whether or not you attend the program. If after registering for the meeting, you find yourself unable to attend, you may send a person in your place provided they are employed by the same institution as you.

Please make checks payable to:

Wyoming Hospital Association
2005 Warren Avenue
Cheyenne, WY 82001

You may FAX your registration to WHA at (307) 632-9347