Please read and complete this form. Return it to the Association Office before Friday, July 20, 2018, by fax at (919) 787-8418, email donnas@nchcfa.org, or by mail to 5109 Bur Oak Circle, Raleigh, NC 27612. Members may be invoiced. Non-members must submit payment with registration.

FACILITY NAME/COMPANY

ADDRESS

CITY/STATE/ZIP

PHONE

EMAIL

All employees of a member/non-member facility must register for a Full Summer Symposium Package. An employee of a facility CANNOT register as a 2018 Trade Associate Member/Guest.

Full Summer Symposium Package: This comprehensive package includes all scheduled activities: admission to all NCHCFA educational sessions, refreshment breaks/continental breakfast at educational sessions, Symposium packet and souvenir, admission into Chairman's Welcoming Reception and Dare to Matter: Rising to the Level of Significance Program & Lunch. Please list the first and last names, as they should appear on badges. Check each event you plan to attend.

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A B C D E F G H I J K

1. License #

2. License #

3. License #

4. License #

2018 Trade Associate Member/Guest Package includes entrance to the Chairman’s Welcoming Reception, Dare to Matter: Rising to the Level of Significance Program & Lunch, and NCHCFA Day at the Beach. Please list the first and last names, as they should appear on badges. Check each event you plan to attend.

2018 Trade Associate Member/Guest Package E I J

1.

2.

ADVANCE REGISTRATION RECEIVED ON/BEFORE 7/20/18

PERSONS @ $400 EACH $

RECEIVED AFTER 7/20/18

PERSONS @ $450 EACH $ Payment Options

TRADE/GUEST REGISTRATION

PERSONS @ $75 EACH $ Check Enclosed

NONMEMBER REGISTRATION

PERSONS @ $800 EACH $ Please Invoice (members only)

TOTAL $