VIRTUAL INTERDISCIPLINARYCONFERENCE

Sessions Available Until December 31, 2020

Please type or print clearly. Complete a separate registration for each registrant.

Registrant Name___________________________________________________ Credentials (RN, LCSW, etc.) _______________________________

Title ____________________________________________________________________________________________________________________________

Registrant E-mail Address (required) ___________________________________________________________________________________________

Organization __________________________________________________________________________________________________________________

Organization Address _________________________________________________________________________________________________________

City ________________________________________________________ State_____________________________________ Zip____________________

Phone___________________________________________________________ Fax _________________________________________________________

❑ Opt Out - Exhibitor Mailing List (email and/or direct)

Group Registration: There will be $50 off for five or more registrations from the same organization. Group registration discounts will be processed and refunded after registration has closed on December 31, 2020.

NHPCO Conference

Member Non-Member Faculty

Rates ❑ $499 ❑ $599 ❑ $325

I would like to donate to the National Hospice Foundation

❑ $5 ❑

$10 ❑ $25 ❑ $50 ❑

$100

Payment

Payment InformationIf payment in full does not accompany this form, your registration will not be processed. Checks must be in US funds. A charge of $25 will apply to checks

NHPCO will charge the remaining amount deemed to be accurate and appropriate to the cardholder listed below.

Registration Cancellation PolicyCancellation requests must be made in writing; a $50 processing fee will apply. Cancellations postmarked on/before October 1, 2020, receive a full refund less the processing fee. Refunds will not be provided for cancellations postmarked

Send cancellation or substitution requests via email conferences@nhpco.org or via fax at (703) 837-1233.

the right to substitute faculty or to cancel or reschedule sessions due to unfore-seen circumstances.

TOTAL FOR THIS ATTENDEE $ __________________________

Check #__________ or ❑ ❑ ❑

CARD NUMBER EXPIRATION DATE

Visa/MC Cvv Code:3-digits back right side

AMEX Cvv Code:4-digits front right side

________________________________________________________________________________________

________________________________________________________________________________________SIGNATURE DATE

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MailNHPCO, 2020 Virtual Interdisciplinary ConferencePO Box 824392, Philadelphia, PA 19182-4392

Overnight DeliveryNC Bank C/O NHPCO, Lockbox #824392Route 38 & East Gate Dr.Moorestown, NJ 08057

Fax(703) 837-1233

Send Your Completed Form