Event Registration

2010 RI Health Center Association Annual Meeting & Candidate Forum

Please fill out the following information to register for the October 14th Annual Meeting & Candidate Forum at the Crowne Plaza.

Registration and payment must be received by September 30th.

Paying by Credit Card: once you submit this form by clicking 'Done', you will be directed to PayPal, where you can pay by American Express,Visa,Mastercard,and Discover. You don't need a PayPal account to make a payment.

Paying by Check: please fill out the registration form, print this page with your information before clicking on the 'Done' button. Make the check payable to the Rhode Island Health Center Association,and mail your check along with a printed copy of the registration form to:

Carmela Hazzard-Viera
Executive Assistant and Project Coordinator
Rhode Island Health Center Association
235 Promenade Street
Suite 104
Providence, RI 02908

*
Please complete the following to register:

Please complete the following to register: Name:
Company:
Title:
Address:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:

If you are registering more than one person for your organization, please include their name and email address in the space below.

*
Payment Method (if paying by check, please print and include this registration form along with your mailed check.)

Payment Method (if paying by check, please print and include this registration form along with your mailed check.) Check

Credit Card

Event Registration

2010 RI Health Center Association Annual Meeting & Candidate Forum

*Please complete the following to register:

If you are registering more than one person for your organization, please include their name and email address in the space below.

*Payment Method (if paying by check, please print and include this registration form along with your mailed check.)

*
Please complete the following to register:

*
Payment Method (if paying by check, please print and include this registration form along with your mailed check.)