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* 1. Practice Name

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* 2. Please provide your first and last name.

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* 3. Please provide an email address where we can contact you if we have questions.

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* 4. Please list all attendees from your practice (including yourself, if applicable). Include first name, last name and credentials as they should appear on the name badges.

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* 6. Please provide an email address corresponding to each attendee above for the pre-event survey and post-event evaluation.

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* 7. Do any attendees from your practice have dietary restrictions? Please check all that apply.

  Food allergy Gluten-free Halal Kosher Vegan Vegetarian Other None
Attendee 1
Attendee 2
Attendee 3
Attendee 4
Attendee 5

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* 8. If anyone from your practice requires accommodations, please describe.

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* 9. Please confirm that you understand that there is a $150 charge per attendee.

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* 10. Please provide the following contact information for the person who will handle payment.

HOTEL ROOM RESERVATIONS:
Have you reserved your room? If you plan to stay overnight on Thursday, April 20th, reservations can be made until April 6, 2017. Call 877-814-2538 or visit http://bit.ly/04_2017_CollaborativeHousing.
The room block rate is $102 per night + 6% state tax and 5% local tax.

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