Registration Packet Template - PDF

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					                                     2009 SUMMER INSTITUTE
                                                        July 31-August 2, 2009
                                                                                  Dearborn, MI


Please complete one full set of information for each individual attending the 2009 Summer Institute.

If you are sending a team of more than 10 individuals, please complete and send a second version
of this form to complete your team registration.

Registration Fee and Payment Information are provided on the second page of this form.

Please complete the Contact Information. The person listed as the contact for your team will receive
confirmation of your team registration within 48 hours of receipt by CQIN.


Attendee Information

Name 1:                                                             CEO or Designee         REP

Special Need(s):




Name 2:                                                             CEO or Designee         REP

Special Need(s):




Name 3:                                                             Team Member

Special Need(s):




Name 4:                                                             Team Member

Special Need(s):




Name 5:                                                             Team Member

Special Need(s):
Name 6:                                                                       Team Member

Special Need(s):




Name 7:                                                                       Team Member

Special Need(s):




Name 8:                                                                       Team Member

Special Need(s):




Name 9:                                                                       Team Member

Special Need(s):




Name 10:                                                                      Team Member

Special Need(s):



Registration Fees:
1. Early Bird Registration with Payment (April 27-May 30, 2009):   $575 per person   NOTE: The Registration Fee
                                                                                     includes Breakfast and Lunch
2. Registration with Payment (June 1-July 6, 2009):                $590 per person
                                                                                     for each day of the Institute.
3. Late Registration or Payment Received after July 10, 2009:      $600 per person
4. Guest College Registration:                                     $625 per person


Institute Fee (see above):


x Number of Attendees:


Total Due:

Payment:

Make check payable to:

 CQIN 2008 Summer Institute
 % Charlotte J. Lee, CQIN Coordinator for Financials & Logistics
 9123 Moody Road
 Fort Smith, AR 72903-6727


      Registration Must be Received by July 10, 2009 to ensure Institute Packet Availability
Contact Information:

Main Contact:


Title::



College:



Phone:



E-Mail:

                            Please Print Form before Sending by E-Mail
                    Once Submitted, the Data is No Longer Available to the Sender
                                                .......
                      Form May be Printed and Sent by FAX to (479) 478-7284




                                                     Print Form


                                                  Submit by E-mail



                If you need assistance with this form, please contact Charlotte J. Lee at (479) 651-6611




                            The Hyatt Regency Dearborn
                        The Hyatt Regency Dearborn will host the 2009 CQIN Summer Institute.

                 Hotel Reservation is Available at the CQIN Rate of $129 per night through July 6, 2009

                                      To Make Your Hotel Reservations Call:
                                                    (800) 233-1234
                                                    (313) 593-1234

				
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