CHA Health Policy Leg Day & Calif Congressional Action Program Registration

				Registration Form
				2008 Health Policy Legislative Day March 5, Sacramento 2008 California Congressional Action Program April 6 – 9, Washington, D.C.

			Your Information:
			*First Name:		Items marked with an asterisk are requied.
			*Last Name:
			*Title :		Nickname for Badge:
			*Company:		*Daytime Phone:
			*Address:		*E-mail:
			*City:
			*State:
			*Zip:

Regular Fee

Save by Registering for Both Events at the Same Time!

Amount

Health Policy Legislative Day — March 5

and Congressional Action Program — April 6 – 9

CHA Member:

$510 per person

Spouse/Guest (includes “Meet & Greet” and Multi-State Dinner):

$175 per person

Spouse/Guest Name for Badge:

Health Policy Legislative Day — March 5, 2008

Amount

CHA Member:

$220 per person

California Congressional Action Program — April 6-9, 2008

Early-Bird Fee

Regular Fee

Amount

(By 3/6/08)

(After 3/6/08)

CHA Member:

at $310 per person

$360 per person

Spouse/Guest (includes Team “Meet & Greet” and Multi-State Dinner):

at $175 per person

$175 per person

Spouse/Guest Name for Badge:

Additional Information
Please answer yes or no to all questions.	Legislative Day	Congressional Action Program
*Are you a first-time attendee?	Yes No	Yes No

*Will you attend VIP Tour of Capitol?	Yes No

*Will you attend Team "Meet & Greet" Reception?	Yes No
If yes, how many will attend?

*Will you attend California Team Luncheon?		Yes No

*Will you attend California Multi-State Dinner?		Yes No
If yes, how many will attend?

What is your hospital's congressional district?			If unsure, go to the U.S. House of Representatives web page, select California in box #1 and enter your hospital's ZIP code in box # 2.

Credit Card Information (Visa, MasterCard or American Express):

*Card Number:

*Security Code:

For Visa/MasterCard, 3 digits from the back of the card in the signature box.
For AMEX 4 digits on the front, above and to the right of the card number.

*Name on Card:

*Exp. Date:

TOTAL:

Comments:

	Mail:	Fax:	Phone:
	Attention: Dawn Vicari California Hospital Association 1215 K St., Ste. 800 Sacramento , CA 95814	(916) 554-2275	(916) 552-7659

ExcelEverywhere