Symposium Registration

For all sponsors, vendors and attendees:

When completing this form please do not use all caps and check your name tag to make sure it is correct before submitting.

For conference attendees and staff:

• If sharing hotel accommodations, each person must register with the hotel and for the Symposium.
• Hotel and Symposium registration must be the same name.
• Lunch will be provided Tuesday through Friday. On the registration form, you must check each day you are requesting lunch. Failure to show for checked lunch will result in 35 GHSP points deducted from your agency.

I have read and acknowledge the above instructions.

Conference Role *    > - role - Conference Staff Speaker Vendor Sponsor

Sponsor Level * - please select - Premier Sponsor ($25,000) Gold Sponsor ($20,000) Silver Sponsor ($15,000) Bronze Sponsor ($10,000) Blue Sponsor ($2,500) Black Sponsor ($750)

Vendor Fee   $300

Title or Rank

First Name *

Middle Name

Last Name *

Suffix

Position

Agency *

Address *

Address 2

City *

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip *

Preferred Phone *   (123-123-1234)

Ext

Email *

Verify email *

Name Tag - First Name *

Name Tag - Last Name *

Tuesday Opening Luncheon*     Yes    No

Wednesday Luncheon*     Yes    No

Thursday Awards Luncheon*     Yes    No

Friday Closing Luncheon*     Yes    No

Dietary Need/Allergy * - please select - Yes No

Dietary Description

Shirt Size - select shirt size - Small Medium Large XL XXL 3XL 4XL

Accommodation/Travel Plans * - please select - Stay at conference hotel Commute daily to conference

Conference Hotel * -please select- Sheraton Raleigh Raleigh Marriott City Center

Hotel Confirmation Number

Arrival Date

Departure Date

Name on Reservation

Name of Roommate

 

Please enter the text displayed in the image.*