CONFERENCE REGISTRATION
(For credit card registrations only. If paying by check or money order, please print our registration form (PDF) and mail it with your payment)

For group rates, please contact our office at (773) 277-2243.

First Name
Last Name
Title
Organization / Institution
Street Address
City
State	Zip
Daytime Phone
Night-time Phone
Fax
Email Address
First Time Conference Attendee?
Conference Last Attended?
Accommodation Information
Campus accomodations needed?	Yes |   No -- If no, skip to continuing education section.
Room Assignment	Please select Male Female Married Couple
Roomate's Name (if known)
Please be sure you have made arrangements with the person you wish to room with and ask them to indicate your name on their registration form.
Arrival Day	Please select May 31 (Thu) June 1 (Fri) June 2 (Sat)
Continuing Education Credits
Select your CE credit category:	Please select Nurse Nurse Practitioner Physician Physician Assistant
Type your name exactly as you would like for it to appear on your CE certificate :
Payment Information
If the registrant's name on your credit card and the registrant's name the same are not the same, provide the card holder's name below. For instance, if you ("Joe Smith") are paying for your registration using your wife's ("Amanda Keller-Smith") credit card, please put the card holder's name ("Amanda Keller-Smith") in the space below.

Additional Instructions

Note: Once you click submit below, you will be redirected to a secure site where you will need to 1> Select your registration type (i.e. Member, Non-Member, Student, etc) and 2> Provide your payment information. Also, if you would like to donate to our Student Scholarship Fund, please make that selection after you have clicked submit.

 

CCHF
P.O. Box 23429
3555 W. Ogden Avenue
Chicago, IL 60623
(773)277-2243

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