Conference Registration
2017 CHAPCA CONFERENCE REGISTRATION
Reset Form
Print Form
Name Hospice/Company Title: Credential Address City
ST
Email
Cell PH
Emergency Contact
Phone
Are you willing to be a session volunteer?
Registration Fees
Zip
Yes
Renaissance Palm Springs Hotel 888 Tahquitz Canyon Way Palm Springs, California 92262
No
EARLY BIRD DISCOUNT (Ends August 31)
REGULAR RATE (September 1 to October 10)
CHAPCA Member
$395
$495
Non-Member
$495
$595
Student, Volunteer, Retired
$250
$350
Speaker/Exhibit Booth Rep
$295
$295
One Day (select day)
Monday
CHAPCA Member
$240
$340
Non-Member
$340
$440
Full Conference
$130
$230
Speaker/Exhibit Booth Rep
$190
$190
Continuing Education Fee
$25
RN
LVN
CNA
Social Work
Please select workshop sessions you wish to attend. Choose one workshop per session. NOTE: Poster sessions are not listed.
Monday, October 9, 2017
Tuesday
Student, Volunteer, Retired
Conference Workshops Concurrent Workshops
1A
1B
Concurrent Workshops
2A
2B
1C 2C
Concurrent Workshops
3A
3B
3C
Concurrent Workshops
4A
4B
4C 5C
Tuesday, October 10, 2017 Concurrent Workshops
5A
5B
Concurrent Workshops
6A
6B
Please check all that apply
HHA
Exhibitor
Hospice Volunteer
Student
Retired
Vegetarian Meals
Vegan Meals
Other
Events (Single ticket included if registered on day of event, but RSVP is required) I DO plan to attend
I DO NOT plan to attend
Opening General Session (Sunday)
Payment Enclosed
Dine Around Palm Springs (Sunday)
Check payable to: CHAPCA
Exhibits Grand Opening, Lunch & Dessert with the Exhibitors (Monday)
Credit Card
Reception with Exhibitors (Monday)
American Express
Breakfast and Poster Session with Exhibitors (Tuesday) Awards Luncheon and CHAPCA Annual Meeting (Tuesday)
Mastercard
Guest Tickets
Visa Card Number: Quantity
Dine Around Palm Springs (Sunday)
Total (If bringing a guest, please RSVP for planning purposes.)
Grand Opening, Lunch & Dessert with the Exhibitors (Monday)
$35
Awards Luncheon
$55
Security Code:
Exp. Date:
Cardholder Name: Signature:
Data is not secure. Do not email.
Send Completed Form with Payment To: CHAPCA, 3841 North Freeway Blvd., Ste. 100, Sacramento, CA 95834; FAX 916-925-3780 Registration with payment must be postmarked by August 31, 2017 to be eligible for the Early Bird registration discount. All registrations beginning September 1 will be at the Regular rate. Confirmation will be sent upon receipt of form and payment. Refunds, less $75 administrative fee, will be made upon written requests submitted by September 8, 2017. No refunds will be given for cancellations received after September 8, 2017. No refunds will be given for "no shows." However, substitutions are welcome. If you have questions about your membership status or wish to make changes to your registration, contact the CHAPCA office at 916-925-3770 or [email protected].
Reset Form
Print Form
Name Hospice/Company Title: Credential Address City
ST
Cell PH
Emergency Contact
Phone
Are you willing to be a session volunteer?
Registration Fees
Zip
Yes
Renaissance Palm Springs Hotel 888 Tahquitz Canyon Way Palm Springs, California 92262
No
EARLY BIRD DISCOUNT (Ends August 31)
REGULAR RATE (September 1 to October 10)
CHAPCA Member
$395
$495
Non-Member
$495
$595
Student, Volunteer, Retired
$250
$350
Speaker/Exhibit Booth Rep
$295
$295
One Day (select day)
Monday
CHAPCA Member
$240
$340
Non-Member
$340
$440
Full Conference
$130
$230
Speaker/Exhibit Booth Rep
$190
$190
Continuing Education Fee
$25
RN
LVN
CNA
Social Work
Please select workshop sessions you wish to attend. Choose one workshop per session. NOTE: Poster sessions are not listed.
Monday, October 9, 2017
Tuesday
Student, Volunteer, Retired
Conference Workshops Concurrent Workshops
1A
1B
Concurrent Workshops
2A
2B
1C 2C
Concurrent Workshops
3A
3B
3C
Concurrent Workshops
4A
4B
4C 5C
Tuesday, October 10, 2017 Concurrent Workshops
5A
5B
Concurrent Workshops
6A
6B
Please check all that apply
HHA
Exhibitor
Hospice Volunteer
Student
Retired
Vegetarian Meals
Vegan Meals
Other
Events (Single ticket included if registered on day of event, but RSVP is required) I DO plan to attend
I DO NOT plan to attend
Opening General Session (Sunday)
Payment Enclosed
Dine Around Palm Springs (Sunday)
Check payable to: CHAPCA
Exhibits Grand Opening, Lunch & Dessert with the Exhibitors (Monday)
Credit Card
Reception with Exhibitors (Monday)
American Express
Breakfast and Poster Session with Exhibitors (Tuesday) Awards Luncheon and CHAPCA Annual Meeting (Tuesday)
Mastercard
Guest Tickets
Visa Card Number: Quantity
Dine Around Palm Springs (Sunday)
Total (If bringing a guest, please RSVP for planning purposes.)
Grand Opening, Lunch & Dessert with the Exhibitors (Monday)
$35
Awards Luncheon
$55
Security Code:
Exp. Date:
Cardholder Name: Signature:
Data is not secure. Do not email.
Send Completed Form with Payment To: CHAPCA, 3841 North Freeway Blvd., Ste. 100, Sacramento, CA 95834; FAX 916-925-3780 Registration with payment must be postmarked by August 31, 2017 to be eligible for the Early Bird registration discount. All registrations beginning September 1 will be at the Regular rate. Confirmation will be sent upon receipt of form and payment. Refunds, less $75 administrative fee, will be made upon written requests submitted by September 8, 2017. No refunds will be given for cancellations received after September 8, 2017. No refunds will be given for "no shows." However, substitutions are welcome. If you have questions about your membership status or wish to make changes to your registration, contact the CHAPCA office at 916-925-3770 or [email protected].
