CSRHA Conference Registration 2009



Registration Type
Scholarship Applicant (for CSRHA members only- no registration fee) Annual Conference CSRHA Member Discount Rate - $280 (includes FREE registration to the Rural e-Health Summit) Save $50 off registration fees! Sign up through October 1st, 2009 and get our Member's 'Early Bird' rate of $230. Annual Conference Standard Registration - $360 (includes a complementary membership to CSRHA for one year and FREE registration to the Rural e-Health Summit)Save $50 off registration fees! Sign up through October 1st, 2009 and get our Non-Member's 'Early Bird' rate of $310. Rural e-Health Summit Only (Member Discount Rate $65) Rural e-Health Summit Only (Non-Member Rate $85)

Please Check All That Apply
I will be attending the e-Health Summit on November 18, 2009 I will be attending the President’s reception on November 18, 2009 I will need disability accommodations for meetings (please inform us by October 12, 2009 and someone will contact you) I will be attending the HRSA Workshop on November 17, 2009. (Space limited to 50 people; first-come, first-served.)

Registration Information
Please complete this form in its entirety. Use one form for each person registering. Please type your name, title and organization as you would like them to appear on your conference name tag.

First Name:
Last Name:
Title:
Organization:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Email:

By clicking the continue button below, you will be taken to a confirmation page where you can review the information you are submitting before completing the transaction. If there are any errors on this page, they will be marked for your review with a red asterisk before allowing you to continue to the confirmation page.

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