Registrant Information
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Pre-Title:
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First Name*:
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Middle Initial:
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Last Name*:
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Suffix:
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For "Other" suffix, please note in Remarks section below. |
Post-Title*:
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For "Other" post-title, please note in Remarks section below. |
Badge Name:
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Enter nickname or leave blank if same as above
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Included for course registrant:
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I will attend the Dinner Session, Friday, Oct 1st
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Included for course registrant:
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I will attend the Lunch Session, Saturday, Oct 2nd
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Kaiser Region:
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Non-Kaiser Facility or Practice*:
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i.e. Group Health Cooperative. Please enter "NA" here if you are a Kaiser affiliate.
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Facility City:
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Facility State:
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Remarks:
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*Enter remarks or custom post-title here.
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How did you hear about this meeting:
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For "Other," please note in Remarks |
Hotel Reservation
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No Hotel Required:
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Check Here if you do not wish to reserve a hotel at this time.
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Check-In Date:
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Use format MM/DD/YYYY; date you will arrive
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Check-Out Date:
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Use format MM/DD/YYYY; date you will depart
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Bed Request:
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Number of beds - Enter 1 or 2; hotel cannot guarantee
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Room Type:
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Arrival and Departure dates need to be entered in field. Room reservation cannot be confirmed without this info.Please note: hotel rate does not include $20/day mandatory valet parking. |
# of Rooms:
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Enter the number of rooms you are requesting
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Special Request:
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*Enter special room requests. Indicate if reserving more than one room, or if sharing a room with another attendee. Hotel cannot guarantee special requests.
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Full Guest Names In This Room
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Guest 1 or Self:
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Guest 2:
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Guest 3:
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Guest 4:
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