Home Infusion Workshop
Presented by: Vital Care, Inc.

Registration Form

May 17-18, 2018

Sheraton Chicago O’Hare Hotel

Rosemont, Illinois

Please complete form in full. Contact Michele Winstead if you have any questions: mhwinstead@vitalcareinc.com or 601-703-2315.

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* 1. First Name:

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* 2. Last Name:

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* 3. Please check one (if applicable):

PharmD

RPh

Student

Other (please specify)

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* 4. Organization/Company:

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* 5. Title:

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* 6. Address:

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* 7. City:

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* 8. State:

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* 9. Zip:

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* 10. Personal Phone Number:

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* 11. Email:

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* 12. *T-shirt Size (Choose one):

2XL

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* 13. Will you be applying for Continuing Education credit?

Yes

If Yes, please enter your license number so we can process your CE Credit:

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* 14. How did you hear about this workshop?

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* 15. Do you have interest in starting your own home infusion business?

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* 16. Comments:

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* 17. Please check if interested:

"Yes, I am interested in attending a Meet and Greet Reception from 1:00-2:00pm on Thursday, May 17th."

"Yes, I am interested in attending a Networking Reception from 5:30-7:00 pm on Thursday, May 17th."

"Yes, I am interested in attending a Dinner Program from 7:00-9:00 pm on Thursday, May 17th."

Space is limited and is granted at a first come, first serve basis.

You will be notified by email once your spot has been reserved.

Hotel Booking Information:

Sheraton Chicago O’Hare Hotel

6501 Mannheim Rd, Rosemont, IL 60018
Reservations: 847-699-6300/888-627-8117
Corporate Room Rate: $169.00
Deadline for making hotel reservations: April 23, 2018