Rooted in the Community

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
• If you have any dietary needs, please enter them. i.e. gluten-free, vegetarian, allergies, etc.
• If you have any special needs as identified by the Americans with Disabilities Act, please enter them.

• *

  I plan to attend the Community Clinic Leadership Hot Topics Workshop on Wednesday, October 4, 9:00 a.m. - 12:00 p.m.

  • Yes
  • No
• *

  I plan to attend the HCCN Quality Forum on Wednesday, October 4, 9:00 a.m. - 12:00 p.m.

  • Yes
  • No
  • I will only attend the HCCN Quality Forum on October 4
• *

  I plan to attend the Preconference session "We All Lead" with Ed O'Malley on Wednesday, October 4, 12:30 - 2:30 p.m.

  • Yes
  • No
• *

  I plan to attend the Community Care Network of Membership Meeting (Community Care Members only) on October 4, 2:30 - 5:00 p.m.

  • Yes
  • No
• *

  Registration

  • Organizational/Associate Member Full Conference includes Preconference session $325
  • Organizational/Associate Member October 5 only $175
  • Organizational/Associate Member October 6 only $175
  • Friends Member: Full Conference includes Preconference session $375
  • Friends Member October 5 only $200
  • Friends Member October 6 only $200
  • Non-Member Full Conference includes Preconference session $425
  • Non-Member October 5 only $250
  • Non-Member October 6 only $250
  • Cover Kansas Navigator (Navigators only) October 4 only
  • Cover Kansas Navigator (Navigators only) Full Conference including Preconference session
  • HCCN Quality Forum on October 4 only

• 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 September 20, 2023, 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 September 20, 2023. "No-Shows" are non-refundable. Responsibility for full payment amount remains if cancellation request is not received by September 20, 2023.

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

• *

  Pay by

  • Check
  • Credit Card (PayPal)
  • Cover Kansas Navigator
  • Only attending HCCN Quality Forum on October 4.
• Name of person to email invoice
• Email address to send invoice

Colleague Information

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