New Meetings Reg Form Template
REGISTRATION FORM
Product ID: 13AOE07
Meeting City: Baltimore, MD Registration Close Date: July 12, 2013 Attendee Information AHIMA ID: This registration is for:
Meeting Date: July 20-24, 2013 (After this date, registration is only available on site.)
I do not have an AHIMA ID. being made on behalf of someone else
myself
First Name:
Middle Initial:
Title:
Last Name: Employer:
Badge/Nickname-Informal Name: Email address:
I do not wish for my contact information to be shared with meeting sponsors, meeting partners, or attendees.
Primary Phone:
Cell Phone:
Additional Attendee Information Emergency Contact Name:
Relationship: This number is: Emergency Contact Telephone: Cell Work I am in need of auxiliary services or aides as defined in the Americans with Disabilities Act.
Home
If you have checked this box, Please identify your audio/visual, speech, mobility needs, or considerations for chronic conditions, so that we may assist you when arrive on site.
Billing & Shipping Info
Billing Address:
Shipping Address: PO BOXES NOT ACCEPTED
Street Address Line 1: Street Address Line 2: City: State: Zip + 4: Country Code:
Early Bird Pricing (available until July 12, 2013) Member Items: 13DR082-Member-Early Bird-FDI-Saturday-only Registration-$235 13DR084-Member-Early Bird-FDI-Sunday-only Registration-$235 13FDIR031-Member-Early Bird-Two-Day FDI Registration-$325 13DR086-Member-Early Bird-AoE-Monday-only Registration-$235 13DR088-Member-Early Bird-AoE-Tuesday-only Registration-$235 13AOER042-Member-Early Bird-4-Day AoE Registration (with Graduate Day and Leadership Institute)-$425 13PCKR062-Member-Early Bird-5-Day FDI & AoE Registration (with Graduate Day and Leadership Institute)-$595
Non-Member Items: 13DR182-Non-Member-Early Bird-FDI-Saturday-only Registration-$335 13DR184-Non-Member-Early Bird-FDI-Sunday-only Registration-$335 13FDIR131-Non-Member-Early Bird-Two-Day FDI Registration-$425 13DR186-Non-Member-Early Bird-AoE-Monday-only Registration-$335 13DR188-Non-Member-Early Bird-AoE-Tuesday-only Registration-$335 13AOER142-Non-Member-Early Bird-4-Day AoE Registration (with Graduate Day and Leadership Institute)-$525 13PCKR162-Non-Member-Early Bird-5-Day FDI & AoE Registration (with Graduate Day and Leadership Institute)-$695
AHIMA AoE Attendee Toll Free Assistance: 866-546-4302/Intl 972-349-5413
Email: [email protected] Page 1 of 3
AHIMA AoE Exhibitor Toll Free Assistance: 877-557-5331/ Intl 972-349-5864
REGISTRATION FORM
Product ID: 13AOE07
Meeting City: Baltimore, MD Registration Close Date: July 12, 2013
Meeting Date: July 20-24, 2013 (After this date, registration is only available on site.)
*
VLab options: 13EAOE202 -VLab Training-The Basics: Saturday, July 20, 8:30 am - 12:30 pm-NO LUNCH-$99 13EAOE203- VLab Training - What's new in VLab: Saturday, July 20, 1:00pm - 4:30 pm-NO LUNCH-$99 13EAOE204- VLab Training - Full Day Session with lunch, Saturday, July 20, 8:30 am - 4:30 pm-includes lunch-$159 13EAOE205- VLab Training - What's new in VLab: Sunday, July 21, 8:30 am - 12:00 pm-NO LUNCH-$99 13EAOE206- VLab Training-The Basics: Sunday, July 21, 1:00 pm - 4:30 pm-NO LUNCH-$99 13EAOE207- VLab Training - Full Day Session with lunch, Sunday, July 20, 8:30 am - 4:30 pm-includes lunch-$159
*
There is no early bird pricing for VLab. Sessions are available for purchase onsite, subject to availability.
Leadership Institute: Leading for Change: 13EAOE201-Member-Early Bird-13E201 Leadership Institute: Leading For Change -$350 13EAOE201N-Non-Member-Early Bird-13E201N Leadership Institute: Leading For Change-$450
On Site Pricing (effective July 13, 2013) 13DR083-Member-Late Registration-FDI-Saturday-only Registration-$335 13DR085-Member-Late Registration-FDI-Sunday-only Registration-$335 13FDIR032-Member-Late Registration-Two-Day FDI Registration-$425 13DR087-Member-Late Registration-AoE-Monday-only Registration-$335 13DR089-Member-Late Registration-AoE-Tuesday-only Registration-$335 13AOER043-Member-Late Registration-4-Day AoE Registration(with Graduate Day and Leadership Institute)-$525 13PCKR063-Member-Late Registration-5-Day FDI & AoE Registration(with Graduate Day and Leadership Institute)-$695 13DR183-Non-Member-Late Registration-FDI-Saturday-only Registration-$435 13DR185-Non-Member-Late Registration-FDI-Sunday-only Registration-$435 13FDIR132-Non-Member-Late Registration-Two-Day FDI Registration-$525 13DR187-Non-Member-Late Registration-AoE-Monday-only Registration-$435 13DR189-Non-Member-Late Registration-AoE-Tuesday-only Registration-$435 13AOER143-Non-Member-Late Reg-4-Day AoE Registration (with Graduate Day and Leadership Institute)-$625 13PCKR163-Non-Member-Late Reg-5-Day FDI & AoE Registration (with Graduate Day and Leadership Institute)$795
Leadership Institute: Leading for Change: 13EAOE201L-Member-Late Registration-Wednesday Only-Leadership Institute: Leading For Change-$450 13EAOE201LN-Non-Member-Late Registration- Wednesday Only Leadership Institute: Leading For Change-$550
Other Items: 13EAOE122-Welcome Reception (additional ticket)-$50 *Graduate Day is not available as a separate purchase. It is available as part of the 4-day AoE or 5-day FDI & AoE Purchase. *The Leadership Institute is part of the 4-day AoE or 5-day FDI & AoE Purchase, or it may be purchased separately.
ORDER TOTAL:
$ 0.00
Payment Information for:
Credit Card: VISA MASTERCARD AMEX Any credit card order may be placed with the Wyndham Jade registration center at: (US) 866-546-4302 (INTL) 972-349-5413 or by email to: [email protected] Please provide the following information for processing payment: Name on Card: Card Number: Expiration Date: Security Code: AHIMA AoE Attendee Toll Free Assistance: 866-546-4302/Intl 972-349-5413
Email: [email protected] Page 2 of 3
DISCOVER
AHIMA AoE Exhibitor Toll Free Assistance: 877-557-5331/ Intl 972-349-5864
REGISTRATION FORM
Product ID: 13AOE07
Meeting City: Baltimore, MD Registration Close Date: July 12, 2013
Meeting Date: July 20-24, 2013 (After this date, registration is only available on site.)
Payment Information for: Approved Amount: $ 0.00 Cardholder Signature: You may also fax your credit card order to our secure fax line: (972) 349-7715
Other Payment Methods
Check: Check Amount: Make check payable to AHIMA. Mail check to AHIMA, Department 77-6331, Chicago, IL 60678-6331 Please note the meeting code and the attendee’s AHIMA number on the memo line.
Are you mailing this form to us? There may be a delay of 7-10 business days in receiving and processing your order.
Purchase Order: PO Number: A copy of the purchase order must accompany this form. POs can only be processed via US post. Please send your form and PO to AHIMA, Department 77-6331, Chicago, IL 60678-6331
Please note the AHIMA Product ID 13AOE07 and the attendee’s AHIMA number on the memo line. Purchase and Attendance Information and Policies Meeting Order Information: Food will be served at this meeting. If you have dietary restrictions, please contact the meetings department: [email protected]
CEUs will be available for attending this meeting. Each credential has its own certification criteria, which may be viewed at: http://ahima.org/downloads/pdfs/certification/ Candidate_Guide.pdf
Payment in full is required before arriving onsite.
Refunds
AHIMA is committed to supporting our customer’s ability to pay using purchase orders. However, all programs must be paid in full prior to the first day of the program. Individuals using purchase orders where payment has not processed by the first day of the program will need to provide a valid credit card to AHIMA to as confirmation of payment and agree that this card will be held up to 10 business days after the last day of the program . At that time if payment has not been made in full AHIMA, AHIMA may process payment using the credit card.
AHIMA provides full refunds less a processing fee of $75 for registration cancellations made up until 61 days prior to the date of the first day of the program. A partial refund of 75% is provided for registration cancellations made between 60 and 46 days prior to the date of the first day of the program. NO REFUNDS are provided within 45 days of the date of the first day of the program. All refunds are processed within 30 days of receipt.
Substitutions
Substitutions (that is, assigning a paid registration to another individual) must be requested at least 31 days prior to the date of the first day of the program. A processing fee of $75 will be invoiced at that time. Substitutions are not accepted within 30 days of the program date and no refund will be.
Submitting requests for refunds, rescheduling, or substitutions
AHIMA reserves the right to modify, cancel or reschedule any event or meeting due to unforeseen circumstances. Registered attendees will be notified of cancellation in advance of program with options of one of the following: 1) re-register for any rescheduled program if available or 2) receive full refund of monies paid forte cancelled program. Cancelled Program Refunds: Refunds for registration fees paid for cancelled programs with no rescheduled options will be paid in full and automatically sent to attendees with 30 days of notification.
Rescheduled Program Refunds: Registrants for rescheduled programs will receive notification instructing registrants about either re-registering for the rescheduled program or obtaining full refund. AHIMA assumes no responsibility for personal expenses. Requests must be submitted in writing to AHIMA Meeting Registrar (Fax: 972-349-7715). Please include the name and date of the program as well as the following information for both the original registrant and the substitute registrant: name, mailing address, phone number, e-mail address, and order reference number. Notification of approval will be made within seven days of receipt of the request.
Force Majeure, and conditions beyond AHIMA’s control: The performance of either party under this agreement is subject to acts of God, war, government regulation, terrorism, disaster, strikes, civil disorder, curtailment of transportation facilities, or any other emergency beyond the parties’ control, making it from an economic, political, or from a personal safety or policy basis inadvisable by a government entity, illegal or impossible to perform their obligations under this agreement or any government or other advisory that travel or meetings are not to be undertaken, either party may cancel this agreement for any one or more of such reasons upon written notice to the other.
AHIMA AoE Attendee Toll Free Assistance: 866-546-4302/Intl 972-349-5413
Email: [email protected] Page 3 of 3
AHIMA AoE Exhibitor Toll Free Assistance: 877-557-5331/ Intl 972-349-5864
Product ID: 13AOE07
Meeting City: Baltimore, MD Registration Close Date: July 12, 2013 Attendee Information AHIMA ID: This registration is for:
Meeting Date: July 20-24, 2013 (After this date, registration is only available on site.)
I do not have an AHIMA ID. being made on behalf of someone else
myself
First Name:
Middle Initial:
Title:
Last Name: Employer:
Badge/Nickname-Informal Name: Email address:
I do not wish for my contact information to be shared with meeting sponsors, meeting partners, or attendees.
Primary Phone:
Cell Phone:
Additional Attendee Information Emergency Contact Name:
Relationship: This number is: Emergency Contact Telephone: Cell Work I am in need of auxiliary services or aides as defined in the Americans with Disabilities Act.
Home
If you have checked this box, Please identify your audio/visual, speech, mobility needs, or considerations for chronic conditions, so that we may assist you when arrive on site.
Billing & Shipping Info
Billing Address:
Shipping Address: PO BOXES NOT ACCEPTED
Street Address Line 1: Street Address Line 2: City: State: Zip + 4: Country Code:
Early Bird Pricing (available until July 12, 2013) Member Items: 13DR082-Member-Early Bird-FDI-Saturday-only Registration-$235 13DR084-Member-Early Bird-FDI-Sunday-only Registration-$235 13FDIR031-Member-Early Bird-Two-Day FDI Registration-$325 13DR086-Member-Early Bird-AoE-Monday-only Registration-$235 13DR088-Member-Early Bird-AoE-Tuesday-only Registration-$235 13AOER042-Member-Early Bird-4-Day AoE Registration (with Graduate Day and Leadership Institute)-$425 13PCKR062-Member-Early Bird-5-Day FDI & AoE Registration (with Graduate Day and Leadership Institute)-$595
Non-Member Items: 13DR182-Non-Member-Early Bird-FDI-Saturday-only Registration-$335 13DR184-Non-Member-Early Bird-FDI-Sunday-only Registration-$335 13FDIR131-Non-Member-Early Bird-Two-Day FDI Registration-$425 13DR186-Non-Member-Early Bird-AoE-Monday-only Registration-$335 13DR188-Non-Member-Early Bird-AoE-Tuesday-only Registration-$335 13AOER142-Non-Member-Early Bird-4-Day AoE Registration (with Graduate Day and Leadership Institute)-$525 13PCKR162-Non-Member-Early Bird-5-Day FDI & AoE Registration (with Graduate Day and Leadership Institute)-$695
AHIMA AoE Attendee Toll Free Assistance: 866-546-4302/Intl 972-349-5413
Email: [email protected] Page 1 of 3
AHIMA AoE Exhibitor Toll Free Assistance: 877-557-5331/ Intl 972-349-5864
REGISTRATION FORM
Product ID: 13AOE07
Meeting City: Baltimore, MD Registration Close Date: July 12, 2013
Meeting Date: July 20-24, 2013 (After this date, registration is only available on site.)
*
VLab options: 13EAOE202 -VLab Training-The Basics: Saturday, July 20, 8:30 am - 12:30 pm-NO LUNCH-$99 13EAOE203- VLab Training - What's new in VLab: Saturday, July 20, 1:00pm - 4:30 pm-NO LUNCH-$99 13EAOE204- VLab Training - Full Day Session with lunch, Saturday, July 20, 8:30 am - 4:30 pm-includes lunch-$159 13EAOE205- VLab Training - What's new in VLab: Sunday, July 21, 8:30 am - 12:00 pm-NO LUNCH-$99 13EAOE206- VLab Training-The Basics: Sunday, July 21, 1:00 pm - 4:30 pm-NO LUNCH-$99 13EAOE207- VLab Training - Full Day Session with lunch, Sunday, July 20, 8:30 am - 4:30 pm-includes lunch-$159
*
There is no early bird pricing for VLab. Sessions are available for purchase onsite, subject to availability.
Leadership Institute: Leading for Change: 13EAOE201-Member-Early Bird-13E201 Leadership Institute: Leading For Change -$350 13EAOE201N-Non-Member-Early Bird-13E201N Leadership Institute: Leading For Change-$450
On Site Pricing (effective July 13, 2013) 13DR083-Member-Late Registration-FDI-Saturday-only Registration-$335 13DR085-Member-Late Registration-FDI-Sunday-only Registration-$335 13FDIR032-Member-Late Registration-Two-Day FDI Registration-$425 13DR087-Member-Late Registration-AoE-Monday-only Registration-$335 13DR089-Member-Late Registration-AoE-Tuesday-only Registration-$335 13AOER043-Member-Late Registration-4-Day AoE Registration(with Graduate Day and Leadership Institute)-$525 13PCKR063-Member-Late Registration-5-Day FDI & AoE Registration(with Graduate Day and Leadership Institute)-$695 13DR183-Non-Member-Late Registration-FDI-Saturday-only Registration-$435 13DR185-Non-Member-Late Registration-FDI-Sunday-only Registration-$435 13FDIR132-Non-Member-Late Registration-Two-Day FDI Registration-$525 13DR187-Non-Member-Late Registration-AoE-Monday-only Registration-$435 13DR189-Non-Member-Late Registration-AoE-Tuesday-only Registration-$435 13AOER143-Non-Member-Late Reg-4-Day AoE Registration (with Graduate Day and Leadership Institute)-$625 13PCKR163-Non-Member-Late Reg-5-Day FDI & AoE Registration (with Graduate Day and Leadership Institute)$795
Leadership Institute: Leading for Change: 13EAOE201L-Member-Late Registration-Wednesday Only-Leadership Institute: Leading For Change-$450 13EAOE201LN-Non-Member-Late Registration- Wednesday Only Leadership Institute: Leading For Change-$550
Other Items: 13EAOE122-Welcome Reception (additional ticket)-$50 *Graduate Day is not available as a separate purchase. It is available as part of the 4-day AoE or 5-day FDI & AoE Purchase. *The Leadership Institute is part of the 4-day AoE or 5-day FDI & AoE Purchase, or it may be purchased separately.
ORDER TOTAL:
$ 0.00
Payment Information for:
Credit Card: VISA MASTERCARD AMEX Any credit card order may be placed with the Wyndham Jade registration center at: (US) 866-546-4302 (INTL) 972-349-5413 or by email to: [email protected] Please provide the following information for processing payment: Name on Card: Card Number: Expiration Date: Security Code: AHIMA AoE Attendee Toll Free Assistance: 866-546-4302/Intl 972-349-5413
Email: [email protected] Page 2 of 3
DISCOVER
AHIMA AoE Exhibitor Toll Free Assistance: 877-557-5331/ Intl 972-349-5864
REGISTRATION FORM
Product ID: 13AOE07
Meeting City: Baltimore, MD Registration Close Date: July 12, 2013
Meeting Date: July 20-24, 2013 (After this date, registration is only available on site.)
Payment Information for: Approved Amount: $ 0.00 Cardholder Signature: You may also fax your credit card order to our secure fax line: (972) 349-7715
Other Payment Methods
Check: Check Amount: Make check payable to AHIMA. Mail check to AHIMA, Department 77-6331, Chicago, IL 60678-6331 Please note the meeting code and the attendee’s AHIMA number on the memo line.
Are you mailing this form to us? There may be a delay of 7-10 business days in receiving and processing your order.
Purchase Order: PO Number: A copy of the purchase order must accompany this form. POs can only be processed via US post. Please send your form and PO to AHIMA, Department 77-6331, Chicago, IL 60678-6331
Please note the AHIMA Product ID 13AOE07 and the attendee’s AHIMA number on the memo line. Purchase and Attendance Information and Policies Meeting Order Information: Food will be served at this meeting. If you have dietary restrictions, please contact the meetings department: [email protected]
CEUs will be available for attending this meeting. Each credential has its own certification criteria, which may be viewed at: http://ahima.org/downloads/pdfs/certification/ Candidate_Guide.pdf
Payment in full is required before arriving onsite.
Refunds
AHIMA is committed to supporting our customer’s ability to pay using purchase orders. However, all programs must be paid in full prior to the first day of the program. Individuals using purchase orders where payment has not processed by the first day of the program will need to provide a valid credit card to AHIMA to as confirmation of payment and agree that this card will be held up to 10 business days after the last day of the program . At that time if payment has not been made in full AHIMA, AHIMA may process payment using the credit card.
AHIMA provides full refunds less a processing fee of $75 for registration cancellations made up until 61 days prior to the date of the first day of the program. A partial refund of 75% is provided for registration cancellations made between 60 and 46 days prior to the date of the first day of the program. NO REFUNDS are provided within 45 days of the date of the first day of the program. All refunds are processed within 30 days of receipt.
Substitutions
Substitutions (that is, assigning a paid registration to another individual) must be requested at least 31 days prior to the date of the first day of the program. A processing fee of $75 will be invoiced at that time. Substitutions are not accepted within 30 days of the program date and no refund will be.
Submitting requests for refunds, rescheduling, or substitutions
AHIMA reserves the right to modify, cancel or reschedule any event or meeting due to unforeseen circumstances. Registered attendees will be notified of cancellation in advance of program with options of one of the following: 1) re-register for any rescheduled program if available or 2) receive full refund of monies paid forte cancelled program. Cancelled Program Refunds: Refunds for registration fees paid for cancelled programs with no rescheduled options will be paid in full and automatically sent to attendees with 30 days of notification.
Rescheduled Program Refunds: Registrants for rescheduled programs will receive notification instructing registrants about either re-registering for the rescheduled program or obtaining full refund. AHIMA assumes no responsibility for personal expenses. Requests must be submitted in writing to AHIMA Meeting Registrar (Fax: 972-349-7715). Please include the name and date of the program as well as the following information for both the original registrant and the substitute registrant: name, mailing address, phone number, e-mail address, and order reference number. Notification of approval will be made within seven days of receipt of the request.
Force Majeure, and conditions beyond AHIMA’s control: The performance of either party under this agreement is subject to acts of God, war, government regulation, terrorism, disaster, strikes, civil disorder, curtailment of transportation facilities, or any other emergency beyond the parties’ control, making it from an economic, political, or from a personal safety or policy basis inadvisable by a government entity, illegal or impossible to perform their obligations under this agreement or any government or other advisory that travel or meetings are not to be undertaken, either party may cancel this agreement for any one or more of such reasons upon written notice to the other.
AHIMA AoE Attendee Toll Free Assistance: 866-546-4302/Intl 972-349-5413
Email: [email protected] Page 3 of 3
AHIMA AoE Exhibitor Toll Free Assistance: 877-557-5331/ Intl 972-349-5864
