Please complete the information below. You will be notified if your submission is accepted.  

Once accepted you will be provided a link to register online for the workshop. Once accepted and registered, the following fees will apply:

  • $225 -- Early Bird Special  --  register before August 28, 2009

  • $250 -- register after August 28, 2009

Cancellations on or prior to August 28, 2009 will be credited to the credit card or refunded to the registrant if paid by a personal check less a $50.00 processing fee. Cancellations beginning August 29, 2009 are not refundable. 

Space is limited.  Alliance of Chicago may limit the number of attendees per organization.

Qualify Form

Name:

 
Organization Name:

Phone Number:

Email Address:

 
City:

 
State:

 
HRSA Region:

 

Is your organization a HRSA-funded grantee from the Midwest Regions (V, ?)

 

Yes No

Is your organization planning to implement an EHRS in 6-12 months?

 

Yes No

Is your organization part of a new or existing network, or considering joining a network?

 

Yes No

If you have answered yes to the above questions, then are you part of the implementation team and want to learn more about successful implementations?

Yes No

Please contact Kristin Betschart with questions.