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IPHCA's 2010 Annual Conference Registration

To Register
Please use this online form to register each attendee. IPHCA must receive payment prior to the conference. There will be no refunds, but you may substitute attendees. All substitutions must be received in writing. The registration fee is listed below and includes breakfast (both days), lunch (both days), breaks, the reception and all conference materials.

Registration Fees
When you register 5 attendees, the sixth one is free!

Location and Hotel Reservations
Indianapolis Marriott North at Keystone at the Crossing
3645 River Crossing Parkway
Indianapolis, IN

Special rate: $120 plus tax/night
Reservation Number: 800-228-9290

Make sure to call the Marriott by September 20th to reserve a room at the group rate. Mention you are with the Indiana Primary Health Care Association Annual Conference. After this date, rooms can only be reserved based on availability.

Please fill out the fields below before submitting the registration form.

First Name *
Last Name *
Title *
Organization *
Street Address *
City, State and Zip *
Email *
Phone Number *
Registration Type *
Member - FQHC Member - State-Funded CHC Member - RHC Non-Member - FQHC Non-Member - State-Funded CHC Non-Member - RHC Non-Member - Other

Please choose which registration type you are submitting. Payment for each type of registration is listed at the beginning of this form.
Special Requests
Vegetarian Meal Requested Require Special Assistance
Do Not Fill This Out

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