Annual Conference Registration - Wisconsin Healthcare Engineering Association

"*" indicates required fields

Today's Date*

Name:*

First Last

Spouse Name:

If you're spouse is accompanying you to the conference, there is an optional Spouse Program they may attend. The cost is $50 and includes them in the spouse activities and all the conference SPECIAL events. You can pay for them on this form or when you arrive at the conference. THIS DOES NOT INCLUDE ANY ADMITTANCE INTO THE EDUCATION SESSIONS.

Organization:*

Title:*

Address:*

Street Address City State Zip

WHEA Chapter:*

If you have actually paid dues to a Chapter, please pick which chapter here. If you have not, pick "Not a WHEA Member"

Email:*

Work Phone:*

First time attending the WHEA Annual Conference?*

Yes

Day Selection:*

- If you are attending one day, indicate which day: (No special events included in one day program)

What type of facility or industry and field do you represent:*

Please Specify Other:*

Registration and Fees: (A full registration includes one ticket to the Thursday evening annual banquet.)*

$280 - Full Annual Conference Registration

$330 - Full Annual Conference Registration WITH SPOUSE PROGRAM

$140 - One Day Annual Conference Registration (includes one day education session only)

Payment Option:*

Comp Code:*

Please provide P.O. Number:*

Comments:

Indicate special needs that you might want us to know about. ( i.e handicap access, Food Allergies, etc)

Total

If payment is to be made by Check or P.O. number, return a copy of your invoice page with check payable to WHEA and mail to:

Wisconsin Healthcare Engineering Association
Jane Bruvold, Administrative Assistant
P.O. Box 374
Woodruff, WI 54568

Telephone: 920.570.4081

info@whea.com

Credit Card*

American Express

Discover

MasterCard

Visa

JCB

Card Number

Expiration Date

Security Code Cardholder Name

Note: See registration flyer for further information on cancellation rules and cancellation fees. All registration fees must be paid in advance. Also note that WHEA events are photographed by a professional photographer for the sole purpose of historically documenting WHEA activities and such photographs may be used by WHEA to promote future WHEA events, conferences and educational programs. Submission of a registration form for any WHEA event constitutes permission for the possible use of the registrants image for future WHEA promotions or historical documentation via hardcopy or on pages of the WHEA website.

Hidden

Registration Unit Price