2013 Part CD QI Initiative Face-to-Face Session Registration

1. Welcome to the Registration Desk

As you know, National Quality Center (NQC) is pleased to offer you the choice between these two 2-day Face-to-Face Session locations. The agenda for each location is the same; no need to attend both.

Please tell us which 2-day session location is a best fit with your schedule.

To download the agenda for these sessions, visit nationalqualitycenter.org/partcd

We look forward to seeing you in June!

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* 1. Your Name

First name:

Last name:

Title:

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* 2. Your Contact Information (you only need 1 mailing address box to move on)

Mailing Address 1

Mailing Address 2

Mailing Address 3

Mailing Address City

Mailing Address State

Mailing Address Zip

Telephone

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* 3. Your Role (check all that apply)

Quality Manager

Medical Leadership

Clinical Provider (with prescribing privileges)

Case Manager/Social Worker

Program Administrator/Operations

Executive Leadership

Other (role description)

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* 4. Your Ryan White Funded Organization

Grantee Name

Grantee City

Grantee State

Grantee Part Funding

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* 5. Networks (check all that apply)

My organization leads a Part C or D network

My organization is part of a Part C or D network

My organization leads a Part A or B network

My organization is part of a Part A or B network

My organization leads or is part of some other clinical or administrative network

I'm not sure

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* 6. Which 2-day Part CD QI Initiative Face-to-Face Session best fits with your schedule? NOTE CHARLESTON SESSION HAS CLOSED. Email Michael@NationalQualityCenter.org to join the waiting list.

New Brunswick, NJ - June 6 and 7, 2013 (best to arrive evening of June 5 if not commuting from home)

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* 7. Accommodations for Face-to-Face Session

New Brunswick Session
Heldrich Hotel (732) 729-4670
10 Livingston Avenue | New Brunswick, NJ
Book Using Reservation ID 213055

Charleston Session
Marriott Charleston (843) 723-3000
170 Lockwood Boulevard | Charleston, SC
Follow this link or call above and refer to "Face to Face Conference" to make reservations
http://www.marriott.com/hotels/travel/chsmc-charleston-marriott/?toDate=6/26/13&groupCode=htrhtra&stop_mobi=yes&fromDate=6/25/13&app=resvlink

If you foresee any issues with your registration or making arrangements for accommodations, please let us know here.