Registration Form - The Leapfrog Group for Patient Safety

By Robert Morgan,2014-03-31 21:21
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Registration Form - The Leapfrog Group for Patient Safety


    18 July, 2006 Swissotel Chicago, IL

Participant Listing Information (please print the following information)

    (* denotes required fields)

First name*:________________________________________________________

    MI: _________ Last name*: __________________________________________

    Title*:_______________________________________________________________________________ Address: ____________________________________________________________________________ City*: _____________________________________ State*: _______________ Postal Code*: ________ Phone*: (with area code) _______________________________ Ext: _________

    Fax*: (with area code) ______________________________________________

    Email Address: _____________________________________________________________

    Please list special dietary requirements: ___________________________________________________ (please submit by July 1, 2006)

    Please list special accessibility requirements: _______________________________________________ (please submit by July 1, 2006)

    Please provide name and number of individual to contact in case of emergency: Name: __________________________________________ Phone Number: ______________________


     Before July 1 After July 1

    Leapfrog Member $100 $125

    Multiple Members* $90 $105

*Multiple registration fees require two or more participants from the same company to submit individual registration forms

    at the same time via fax or mail. List colleagues names in the space below.

    Name: __________________________________ Name: _____________________________________

Total Conference Registration Fee $__________________

Payment Information

    If you have any questions about whether your organization is a member of The Leapfrog Group, please contact Cedric

    Calhoun, Director, Membership & Marketing at The Leapfrog Group at or 202-292-6725.

Check# _________

; Visa ; MasterCard

    Account #: ____________________________________ Exp. Date: _____________ Billing Postal Code: ______ Name as it appears on the card: ________________________________________________________________ Signature: __________________________________________________________________________________ Send registration and payment payable to The Leapfrog Group

    By mail: The Leapfrog Group, PO Box 630453, Baltimore, MD 21263-0453

    FAX: 202.292.6825 (credit card)

    Questions: Call Cedric Calhoun at 202-292-6725 or Rachel Weissburg at 202-292-6713

The Leapfrog Group Registration Policies

    Confirmed registration:

    Leapfrog Group membership is organization based and must be paid in full to qualify to attend this meeting. Only registrations received with payment are processed and confirmed. Written confirmation is forwarded via email upon processing of registrations received with payment. You must have a written confirmation to be considered confirmed for the meeting. Make checks payable to The Leapfrog Group.

Where applicable, meeting fees include conference materials, refreshment breaks and meals.

    Deadlines: Early registration is encouraged. All registrations should be received at The Leapfrog Group no later than July 1, 2006. After July 1, 2006, please contact Cedric Calhoun (202-292-6725) for registration options. Registrations received by the registration deadline will be included in a Participant Listing that will be sent to you via email in a PDF format.

    Cancellations and Refunds: Cancellations submitted to The Leapfrog Group in writing by 5:00 pm (ET) on July 1, 2006 will be eligible for a refund, minus a $15 administrative fee. Refunds will be processed after the meeting. Forward cancellation notifications in writing to; fax: 202-292-6825. The Leapfrog

    Group does not accept phone cancellations.

    Refunds will not be granted without written notification by the deadline, for failure to attend, late arrivals, balance-due registrations received after the registration deadline or chances to the agenda or speaker roster.

    Substitutions: Substitutions are accepted with written notification from the original registrant in advance of meeting.

    Meeting cancellation: The Leapfrog Group reserves the right to cancel any meeting at its discretion, whereupon all registration fees will be refunded. The Leapfrog Group will not be responsible for airfare penalties or other costs incurred due to a cancellation.

Agenda/Speakers: Subject to change without notice.

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