Power of the Past - Force of the Future

Personal Information

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:

Business Information

• * Company:
• * Job Title:
• * Address 1:
• Address 2:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Phone:

• *

  Preferred Pronouns

  • She / Her
  • He / Him
  • They / Them
  • Other
  • Prefer not to answer
• *

  What is your social distancing comfort level?

  • Red: Greet from 6 feet
  • Yellow: Elbows, fist bumps
  • Green: Handshakes and high fives approved
• *

  Do you have any special dietary needs?

  • No
  • Yes - Gluten free
  • Yes - Vegetarian
  • Yes - other (please contact Kari Parker with your needs)
• *

  Do you have any special needs as identified by the Americans with Disabilities Act?

  • No
  • Yes (please contact Kari Parker with your needs)
• *

  I plan to attend the HCCN Quality Forum

  • Yes - HCCN Member
  • Yes - Non HCCN Member
  • No
• *

  I plan to attend the Navigator Pre-Conference Session (For Navigators only)

  • Yes
  • No

• *

  I plan to attend the CFO pre-conference meeting on October 5? (For Finance Leadership)

  • Yes
  • No
• *

  I plan to attend the Community Care Network of Membership Meeting (Community Care Members only) on October 5.

  • Yes
  • No

• Organization / Associate Member

  • Pre-Conference Session $75
  • Pre-Conference Session and Full Conference $305
  • Full Conference only $275
  • October 6 only $175
  • October 7 only $175

• Friends Member

  • Pre-Conference only $75
  • Pre-Conference Session and Conference $355
  • Conference only $325
  • One Day rate October 6 $200
  • One Day rate October 7 $200

• Non-Member

  • Pre-Conference only $75
  • Pre-Conference and Full Conference $405
  • Conference only $375
  • One Day rate October 6 $275
  • One Day rate October 7 $275

• Registration fee includes program materials, meals and refreshments. Community Care Network of Kansas strongly encourages and accepts substitutions for registered attendees at any time. All cancellation requests must be received in writing by August 19, 2022, and will be assessed a $25 processing fee (per person). To cancel or request a substitution for registration please contact Community Care (kparker@communiytcareks.org). No Refunds will be issued after August 19. "No-Shows" are non-refundable. Responsibility for full payment amount remains if cancellation request is not received by August 19, 2022.

• *

  Pay by

  • Check
  • Credit Card (PayPal)

• Invoices will be emailed to the person indicated within 5 - 7 business days.

• * Name of person to email invoice
• * Email address to send invoice

Guest Information

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