Attendee Conference Registration Form by ths54408

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									                                          37TH ANNUAL EDUCATIONAL CONFERENCE & INTERNATIONAL MEETING
                                                                                                                                                                                                                      Register Online at
                                          Attendee Conference Registration Form                                                                                                                                          www.apic.org/
                                                                                                                                                                                                                                ac2010
                                          July 11-15 | New Orleans Morial Convention Center | New Orleans, LA

STEP     1           Attendee Information                                                                                                                                                                TOTAL $
                                                                                                                                                                                                 *Numbers required for membership discounts


       APIC Member ID#*                                                               SHEA Member ID#*                                                            CHICA Member ID#*

       Not an APIC member? Join now to receive conference discounts.
        Yes, I want to become an APIC member: U.S. Citizen/Canada: $180.00                                              International: $200.00 (If already a member, enter $0.00 above)


       Last Name                                                                      First Name                                                                  MI               Nickname for Badge


       Title                                                                                                       Credentials                                    Company/Employer Name


       Preferred Mailing Address  Home                     Work


       City                                                                                                        State/Province                                 Zip/Postal Code                     Country


       Phone                                                        Fax                                                            Email address (Required; confirmations will be sent via email)
               If you require special accommodations due to disability, health concerns or physical challenges please contact the APIC conference manager at 703.964.1240 ext. 14 or APICConferenceManager@conferencemanagers.com


STEP     2           Conference Registration                                                                                                                                                             TOTAL $
       Optional events in steps 3 - 9 are NOT included in any conference registration package and must be purchased or signed up for separately. One-day registration
       can only be used for ONE day; two or more days require full conference registration.
                                                                                                                                                 Early                   Regular
       Check the box next to your selection                                                                                                    By May 17               May18-June 28              On-site                          Total
       201.        Member (Full registration)                                                                                                  $520                     $620                     $670                    $
       202.        Non-Member (Full registration)                                                                                              $820                     $920                     $970                    $
       203.        Student (Full registration) Student ID required at check-in                                                                 $150                     $200                     $200                    $
       204.        One Day, Member (circle day)           MON    TUES    WED   THURS                                                           $295                     $295                     $295                    $
       205.        One Day, Non-Member (circle day)       MON    TUES    WED   THURS                                                           $410                     $410                     $410                    $


STEP      3         Pre-Conference Workshop                                                                                                                                                              TOTAL $
       The program below is NOT included in any conference registration package.
       Workshop                                                                                              Date/Time                        Attendee Limit                  Member           Non-Member                         Total
       301. The Basics of Performance Improvement                                           Sunday, July 11 / 8am–5pm                               75                         $195                 $245                  $

STEP      4         Optional Professional Development Workshops*                                                                                                                                                 TOTAL $ 0.00
       These events are free; however, please indicate below if you wish to attend. Tickets will be issued to those who sign up. Space is limited, so we ask that you
       register only if you intend to participate. Must be registered for the full conference to attend.
       Workshop                                                                                                                                     Date/Time                                         Capacity           FREE (please check
                                                                                                                                                                                                                        box if you will attend)
       401. Getting It Right! Learning How to Use the NHSN Surveillance Definitions   Monday, July 12 / 3:00 pm – 5:00 pm                                                                              No limit               Will attend
       402. Evidence-Based Emergency Management for H1N1 and                          Monday, July 12 / 3:00 pm – 5:00 pm
            Other Biological Events                                                                                                                                                                          100              Will   attend
       403. Hop on the Bus, Gus: Myths and Mysteries of Engagement                    Tuesday, July 13 / 1:30 pm – 4:00 pm                                                                                   100              Will   attend
       404. From Risk Assessment to Infection Control Plan: Learning the Steps        Tuesday, July 13 / 1:30 pm – 4:00 pm                                                                                   100              Will   attend
       405. Got Risk? Minimizing and Mitigating Your Risk Exposure                    Tuesday, July 13 / 1:30 pm – 4:00 pm                                                                                   100              Will   attend
       406. Speak Up and Stand Out: Mastering the Art of Influence                  Wednesday, July 14 / 1:30 pm – 5:00 pm                                                                                   100              Will   attend
       407. You Too Can Write an Abstract                                           Wednesday, July 14 / 1:30 pm – 5:00 pm                                                                                   100              Will   attend

       Instructions                                                                      will be no refunds for cancellations received after June 28, 2010.
                                                                                         No-shows are non-refundable. All conference refunds will be processed
                                                                                                                                                                          Complete both sides of this form and send with final payment to:
                                                                                                                                                                          APIC 2010
       1. Please print all information.                                                  3-5 weeks after receipt of the written cancellation.                             c/o Laser Registration
       2. Use separate form for each attendee registration.                                                                                                               1200 G Street, NW Suite 800
                                                                                       7. Pre-Conference Workshop and Meet-the-Expert Session Cancella-
       3. Payment must be in U.S. dollars.                                                                                                                                Washington, DC 20005-6705
                                                                                          tions: All pre-conference cancellations must be received at APIC
       4. Payment must accompany all registrations (NO exceptions).
                                                                                          headquarters at education@apic.org or faxed to (202) 789-1899.
       5. Payment may be made by check, payable to APIC,
                                                                                          Cancellations for any pre-conference activity will be processed after            Check here if you do not wish to be included in promotional mailings
          or by American Express, VISA, or MasterCard.                                                                                                                    from APIC exhibitors sent prior to APIC 2010. Promotional mailings often
                                                                                          the annual conference. Please note that no cancellations will be
       6. Cancellation Policy: All cancellation requests must be received by APIC         accepted for Meet-the-Expert sessions.                                          include special exhibitor-sponsored events and reception invitations.
          headquarters in writing (via fax or email) prior to the start of the con-                                                                                       The APIC 2010 mailing is limited to a one-time usage and does not in-
                                                                                       8. Program Cancellation: In the unlikely event of conference cancellation,
          ference on July 11, 2010. An 80% refund will be given if the request is                                                                                         clude phone, fax, or email.
                                                                                          APIC will refund 100 percent of registration fees paid. APIC assumes
          received on or prior to the Early Registration deadline (May 17, 2010). A
                                                                                          no liability for any penalty fees on airline tickets, deposits for hotel
          70% refund will be given if request is received after May 17, 2010, but
                                                                                          accommodations, or any other fees, charges, penalties, or other incidental
          before June 28, 2010. Please submit cancellation requests to APIC
                                                                                          costs that a registrant might incur as a consequence of cancellation.
          headquarters at education@apic.org or fax to (202) 789-1899. There

       For additional information, contact Conference Registration at 514-380-5394 or apic@laser-registration.com. Be sure to complete both sides of this registration form.
       Last Name                                                              First Name


STEP     5       Optional Orientation Sessions*                                                                               TOTAL $ 0.00                         STEP    11          Total Fees
       These events are free; however, please indicate below if you wish to attend. Tickets will be issued to those                                                TOTAL FEES FROM STEPS
       who sign up. Space is limited, so we ask that you register only if you intend to participate.                                                               Total Step I ..............................$_____________
       Session                                                                             Date/Time                      Attendee       FREE (please check
                                                                                                                                                                   Total Step 2 ............................$_____________
                                                                                                                              Limit     box if you will attend)    Total Step 3 ............................$_____________
                                                                                                                                                                                                                0.00
                                                                                                                                                                   Total Step 4 ............................$_____________
       501. First-Time Attendee Orientation    Sunday, July 11/ 3:30 pm – 4:30 pm                                              75             Will attend         Total Step 5 ............................$_____________
                                                                                                                                                                                                                0.00
       502. International Attendees Orientation Sunday, July 11/ 3:30 pm – 4:30 pm                                             75             Will attend         Total Step 6 ............................$_____________
                                                                                                                                                                   Total Step 7 ............................$_____________
STEP     6       Optional Meet-the-Expert Sessions                                                                    TOTAL $                                      Total Step 8 ............................$_____________
                                                                                                                                                                   Total Step 9 ............................$_____________
       These sessions are optional. Limited to 25 people per session. Tickets will be issued to participants.
       Member/Non-Member Early/Regular Rate - $65 per Session. (Meals included).                                                                                   GRAND TOTAL (ADD STEPS 1-9)                $_____________
       Wednesday July 14                             Wednesday July 14                                           Wednesday July 14
       Morning Sessions 6:45am-7:45am                Afternoon Sessions 12:30pm-1:30pm                           Evening Sessions 5:15pm-6:15pm
       601.    Infection Prevention in Dialysis     606.       Best Practice for IP in Ambulatory Care (I)     611.  Best Practice for IP in Ambulatory         STEP    12          Payment Information
                                                                                                                            Care (III)                              Enclosed is my check for $ _____________
       602.    Investigating Clusters               607.       Best Practice for IP in Ambulatory Care (II)    612.      Best Practices for IP in               payable to APIC (See Grand Total All Fees above).
                                                                                                                            Occupational/Employee Health
       603.    Unique Challenges Associated with    608.       Best Practice for IP in Behavioral Care         613.      Investigating Clusters                 Checks will be processed electronically. If you do not
                 Preventing Infections in Pediatrics                                                                                                               want your check converted electronically, please select
       604.     Sterile Processing in All Settings (I) 609.    Best Practice for IP in Long-Term Care (LTC)    614.  Sterile Processing in All Settings (II)    another method of payment such as by credit card.
       605.    To be determined                     610.       Best Practice for the Prevention of Multidrug   615.  Unique Challenges Associated with           Please charge my credit card: (check one)
                                                                   Resistant Organisms                                       Preventing Infections in Pediatrics
                                                                                                                                                                    AMEX  VISA  MasterCard
                                                                                                 ( ___# of Sessions x $65 each = $________ )
                                                                                                                                                                   _________________________________________
STEP     7       Optional Poster Rounds with Professor                                                                TOTAL $                                      CARD#
                                                                                                                                                                   _________________________________________
       Tickets will be issued to those who sign up. $10 Donation to the APIC Research Foundation, a Division of APIC.                                              EXP. DATE
       One ticket per person, per round. (Limit: 10 people per round)                                                                                              _________________________________________
                                                                                       Date/Time                                                                   NAME ON CARD (PRINT)
       701. Poster Rounds with Professors                                                Tuesday, July 13 / 10:30 am – 11:30 am                                    _________________________________________
                                                                                                                                                                   SIGNATURE
       702. Poster Rounds with Professors                                            Wednesday, July 14 / 10:30 am – 11:30 am
                                                                                                                                                                   Your signature authorizes your credit card to be
                                                                                                                                                                   charged for the total payment due. APIC reserves the
STEP
         8       Optional Shuttle Bus Pass                                                                            TOTAL $                                      right to charge the correct amount if different from
                                                                                                                                                                   the total listed.
       Do not select this option if you are booking your hotel through the APIC Housing Bureau. Shuttle bus passes are free only to
       those attendees who are staying at an APIC official conference hotel. Please support your organization and help APIC                                        Billing Address: (required – must match card billing address)
       avoid hotel attrition fees. All of APIC conference hotels include complimentary shuttle bus service to and
       from the New Orleans Morial Convention Center.                                                                                                              _________________________________________

       If you choose not to stay at an official conference hotel, you will need to purchase a shuttle bus pass for                                                 _________________________________________
       $75.00 in order to ride the conference shuttle buses. Passes are good for the entire conference.                                                            _________________________________________
       No one-day passes available.
                                                                                                                                                                   Fax: 514-380-5395
       801. Shuttle Bus Pass (Free only to those attendees who are staying at an APIC conference hotel)                                           $75.00          (Must include credit card number for payment)
                                                                                                                                                                   X To avoid duplicate charges, please either mail or fax
STEP     9       Optional 2010 Annual Conference Audio Recordings                                                     TOTAL $                                      your registration – DO NOT DO BOTH.
                                                                                                                                                                   For additional information, contact Conference Registration
       (special rate for 2010 attendees only)                                                                                                                      at 514-380-5394 or apic@laser-registration.com
       901. 2010 Annual Conference Audio Recordings Complete web-based compilation                                                                $99.00
                                                                                                                                                                   Be sure to complete both sides of this registration form.


STEP    10         Demographic Information
  A. How many times have you attended the APIC Annual Conference?                               a.  This is my first time                b.  2-4 times            c.  5-7 times            d.  Over 8 times
  B. How long have you been an APIC member?                        a.  Just Joined             b.  1-3 years            c.  4-6 years            d.  6-9 years          e.  10+ years             f.  Not a member
  C. Professional Status
     a.  Administrator/COO e.  Dentist                                             i.  Epidemiologist                      n.  Microbiologist     r. Quality/Process                      u.  RN
     b.  Clinical Pathologists f.  Employee Health                                 j.  Infectious Disease MD               o.  Nurse Practitioner      Improvement                         v.  Safety Officer
     c.  CMO                   g.  EMT/Emergency                                  k.  LPN/LVN                              p.  PharmD             s. Researcher                           w. Surgeon
     d.  CNO                        Preparedness Agency                             l.  Medical Doctor MD                   q.  Public Health      t.  Risk Manager                        x. Other: ______________
                                h.  Engineer/Architect                             m.  Medical Technologist
  D. Practice Setting
     a.  Acute Care Inpatient/Outpatient Program/Services                               f.  Disaster/Emergency Preparedness                        k.  Military                       o.  Surgery Center
     b.  Ambulatory Care                                                                g.  EMS/First Responder                                     l.  Pediatrics                    p.  University/School
     c.  Behavioral Health                                                              h.  Home Care                                              m.  Public Health,                 q.  Veteran’s Affairs
     d.  Correction/Detention                                                            i.  Hospital Based Clinic                                       Community Health              r.  Other: __________________
     e.  Dialysis Center                                                                j.  Long-term Care                                         n.  Self-Employed
  E. Highest Educational Level                a.  1 year technical                b.  Diploma                c.  Associate Degree               d.  Bachelor’s             e.  Master’s            f.  PhD           g.  MD
  F. Years in Infection Control               a.  Less than 1                     b.  1-3                    c.  4-9                 d.  10 or more                    e.  N/A
  G. Are you CIC certified?                   a.  Yes                  b.  No
  H. Years in Healthcare?                     _________                                           www.apic.org/ac2010 | July 11-15 | New Orleans, LA

								
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